- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.82 / $1,388.82 / $1,400.00
| Facility | | $1,388.82 | $1,388.82 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.82 / $1,452.48 / $1,626.80
| Professional | | $1,388.82 | $1,452.48 | $1,626.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,391.33 / $1,593.85 / $1,736.53
| Facility | | $1,391.33 | $1,593.85 | $1,736.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.58 / $1,543.58 / $1,543.58
| Professional | | $1,543.58 | $1,543.58 | $1,543.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,490.36 / $1,490.36 / $1,490.36
| Facility | | $1,490.36 | $1,490.36 | $1,490.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.78 / $1,970.31 / $7,881.06
| Professional | | $1,243.78 | $1,970.31 | $7,881.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.79 / $1,610.36 / $2,418.17
| Professional | | $1,081.79 | $1,610.36 | $2,418.17 |