- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $973.77 / $973.77 / $973.77
| Facility | | $973.77 | $973.77 | $973.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.77 / $973.77 / $3,822.00
| Professional | | $973.77 | $973.77 | $3,822.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $534.44 / $702.94 / $1,359.70
| Facility | | $534.44 | $702.94 | $1,359.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $973.77 / $1,606.72 / $1,898.85
| Facility | | $973.77 | $1,606.72 | $1,898.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.02 / $1,420.02 / $1,420.02
| Professional | | $1,420.02 | $1,420.02 | $1,420.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.13 / $144.12 / $144.12
| Facility | | $141.13 | $144.12 | $144.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.16 / $137.33 / $144.12
| Professional | | $128.16 | $137.33 | $144.12 |