- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,239.33 / $1,239.33 / $3,186.86
| Facility | | $1,239.33 | $1,239.33 | $3,186.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.33 / $1,664.25 / $1,664.25
| Professional | | $1,239.33 | $1,664.25 | $1,664.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,665.02 / $3,567.52 / $3,983.58
| Professional | | $2,665.02 | $3,567.52 | $3,983.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.44 / $2,034.44 / $2,986.65
| Professional | | $2,034.44 | $2,034.44 | $2,986.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,062.29 / $1,345.56 / $3,186.86
| Facility | | $1,062.29 | $1,345.56 | $3,186.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.94 / $2,124.58 / $3,540.96
| Professional | | $902.94 | $2,124.58 | $3,540.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.60 / $1,805.89 / $3,009.82
| Professional | | $743.60 | $1,805.89 | $3,009.82 |