- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.16 / $1,055.16 / $1,055.16
| Facility | | $1,055.16 | $1,055.16 | $1,055.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.18 / $739.18 / $1,055.16
| Professional | | $739.18 | $739.18 | $1,055.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.37 / $1,938.33 / $1,971.83
| Professional | | $1,656.37 | $1,938.33 | $1,971.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.75 / $1,443.04 / $1,814.51
| Professional | | $1,428.75 | $1,443.04 | $1,814.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.02 / $1,055.16 / $6,508.31
| Facility | | $87.02 | $1,055.16 | $6,508.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.37 / $712.16 / $1,024.08
| Professional | | $489.37 | $712.16 | $1,024.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.95 / $682.72 / $1,024.08
| Professional | | $406.95 | $682.72 | $1,024.08 |