- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,276.98 / $1,276.98 / $1,276.98
| Facility | | $1,276.98 | $1,276.98 | $1,276.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.60 / $894.60 / $1,276.98
| Professional | | $894.60 | $894.60 | $1,276.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.47 / $2,345.69 / $2,386.23
| Professional | | $2,004.47 | $2,345.69 | $2,386.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.75 / $1,746.04 / $2,195.51
| Professional | | $1,728.75 | $1,746.04 | $2,195.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.30 / $1,276.98 / $7,874.71
| Facility | | $105.30 | $1,276.98 | $7,874.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.36 / $861.71 / $1,239.49
| Professional | | $592.36 | $861.71 | $1,239.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.41 / $861.71 / $1,239.49
| Professional | | $492.41 | $861.71 | $1,239.49 |