- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,231.19 / $1,231.19 / $1,231.19
| Facility | | $1,231.19 | $1,231.19 | $1,231.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.55 / $1,172.56 / $1,231.19
| Professional | | $295.55 | $1,172.56 | $1,231.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.14 / $1,328.03 / $1,593.64
| Professional | | $506.14 | $1,328.03 | $1,593.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.19 / $1,172.56 / $1,172.56
| Facility | | $1,106.19 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,172.56
| Professional | | $1,172.56 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $290.89 / $1,207.73 / $2,051.98
| Facility | | $290.89 | $1,207.73 | $2,051.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.89 / $290.89 / $290.89
| Professional | | $290.89 | $290.89 | $290.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $1,231.18 / $1,550.25
| Professional | | $55.00 | $1,231.18 | $1,550.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.76 / $1,172.56 / $1,289.82
| Professional | | $1,078.76 | $1,172.56 | $1,289.82 |