- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,059.14 / $1,059.14 / $1,059.14
| Facility | | $1,059.14 | $1,059.14 | $1,059.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.65 / $729.65 / $1,059.14
| Professional | | $729.65 | $729.65 | $1,059.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,104.03 / $3,632.42 / $3,695.21
| Professional | | $3,104.03 | $3,632.42 | $3,695.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.75 / $1,246.08 / $1,566.86
| Professional | | $1,233.75 | $1,246.08 | $1,566.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $729.65 / $1,059.86 / $5,936.57
| Facility | | $729.65 | $1,059.86 | $5,936.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.86 / $847.32 / $1,260.92
| Professional | | $601.86 | $847.32 | $1,260.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.58 / $1,084.90 / $1,260.92
| Professional | | $446.58 | $1,084.90 | $1,260.92 |