- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,266.07 / $1,266.07 / $2,690.40
| Facility | | $1,266.07 | $1,266.07 | $2,690.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.52 / $1,025.52 / $1,025.52
| Professional | | $1,025.52 | $1,025.52 | $1,025.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.64 / $1,440.00 / $1,440.00
| Professional | | $759.64 | $1,440.00 | $1,440.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.07 / $1,266.07 / $1,278.73
| Professional | | $1,266.07 | $1,266.07 | $1,278.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,266.07 / $1,266.07 / $2,051.03
| Facility | | $1,266.07 | $1,266.07 | $2,051.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.52 / $1,025.52 / $1,266.07
| Professional | | $1,025.52 | $1,025.52 | $1,266.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.70 / $759.64 / $2,215.62
| Professional | | $645.70 | $759.64 | $2,215.62 |