- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.66 / $1,060.66 / $1,060.66
| Facility | | $1,060.66 | $1,060.66 | $1,060.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.96 / $931.96 / $1,060.66
| Professional | | $931.96 | $931.96 | $1,060.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.09 / $1,611.66 / $1,651.75
| Professional | | $1,363.09 | $1,611.66 | $1,651.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.00 / $1,302.90 / $1,638.30
| Professional | | $1,290.00 | $1,302.90 | $1,638.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $491.90 / $1,060.66 / $5,694.72
| Facility | | $491.90 | $1,060.66 | $5,694.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.58 / $818.22 / $1,161.58
| Professional | | $462.58 | $818.22 | $1,161.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.65 / $727.31 / $1,161.58
| Professional | | $363.65 | $727.31 | $1,161.58 |