- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,242.08 / $1,242.08 / $1,400.00
| Facility | | $1,242.08 | $1,242.08 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.73 / $1,277.10 / $1,500.48
| Professional | | $1,104.73 | $1,277.10 | $1,500.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,265.29 / $1,443.64 / $1,572.86
| Facility | | $1,265.29 | $1,443.64 | $1,572.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.10 / $1,398.10 / $1,398.10
| Professional | | $1,398.10 | $1,398.10 | $1,398.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,356.50 / $1,356.50 / $1,356.50
| Facility | | $1,356.50 | $1,356.50 | $1,356.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.71 / $1,747.62 / $7,857.18
| Professional | | $1,142.71 | $1,747.62 | $7,857.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.48 / $1,470.02 / $2,109.98
| Professional | | $932.48 | $1,470.02 | $2,109.98 |