- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,154.04 / $1,154.04 / $1,154.04
| Facility | | $1,154.04 | $1,154.04 | $1,154.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.50 / $1,062.45 / $1,296.16
| Professional | | $1,007.50 | $1,062.45 | $1,296.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.69 / $1,707.87 / $1,750.35
| Professional | | $1,451.69 | $1,707.87 | $1,750.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.50 / $1,507.43 / $1,895.48
| Professional | | $1,492.50 | $1,507.43 | $1,895.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.81 / $1,154.04 / $3,462.12
| Facility | | $185.81 | $1,154.04 | $3,462.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.74 / $107.47 / $4,206.60
| Professional | | $53.74 | $107.47 | $4,206.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.12 / $107.47 / $4,206.60
| Professional | | $52.12 | $107.47 | $4,206.60 |