- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,006.50 / $1,006.50 / $1,006.50
| Facility | | $1,006.50 | $1,006.50 | $1,006.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.58 / $659.43 / $1,006.50
| Professional | | $367.58 | $659.43 | $1,006.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $985.78 / $1,075.53 / $1,140.81
| Facility | | $985.78 | $1,075.53 | $1,140.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.55 / $1,067.55 / $1,067.55
| Professional | | $1,067.55 | $1,067.55 | $1,067.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $713.15 / $713.15 / $713.15
| Facility | | $713.15 | $713.15 | $713.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.60 / $713.14 / $1,891.41
| Professional | | $520.60 | $713.14 | $1,891.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.58 / $979.58 / $6,073.14
| Facility | | $367.58 | $979.58 | $6,073.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $379.58 / $606.38 / $1,552.83
| Professional | | $379.58 | $606.38 | $1,552.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.57 / $606.38 / $847.93
| Professional | | $385.57 | $606.38 | $847.93 |