- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,263.53 / $2,685.00
| Facility | | $1,263.53 | $1,263.53 | $2,685.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.46 / $1,023.46 / $1,023.46
| Professional | | $1,023.46 | $1,023.46 | $1,023.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.49 / $7.49 / $821.29
| Professional | | $7.49 | $7.49 | $821.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,263.53 / $1,276.17
| Professional | | $1,263.53 | $1,263.53 | $1,276.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,263.53 / $2,046.92
| Facility | | $1,263.53 | $1,263.53 | $2,046.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.46 / $1,023.46 / $1,263.53
| Professional | | $1,023.46 | $1,023.46 | $1,263.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.40 / $758.12 / $2,211.17
| Professional | | $644.40 | $758.12 | $2,211.17 |