- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,801.27 / $1,801.27 / $2,285.55
| Facility | | $1,801.27 | $1,801.27 | $2,285.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,801.27 / $1,801.27 / $1,801.27
| Professional | | $1,801.27 | $1,801.27 | $1,801.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $143.26
| Professional | | $143.26 | $143.26 | $143.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $60.00 / $2,438.17
| Professional | | $45.00 | $60.00 | $2,438.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.90 / $252.48 / $265.76
| Professional | | $204.90 | $252.48 | $265.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.19 / $2,170.19 / $2,170.19
| Professional | | $2,170.19 | $2,170.19 | $2,170.19 |