- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,437.17 / $1,437.17 / $1,724.60
| Facility | | $1,437.17 | $1,437.17 | $1,724.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.17 / $1,493.53 / $1,743.08
| Professional | | $1,437.17 | $1,493.53 | $1,743.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.20 / $1,505.20 / $1,505.20
| Professional | | $1,505.20 | $1,505.20 | $1,505.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,950.00 / $1,950.00 / $1,950.00
| Facility | | $1,950.00 | $1,950.00 | $1,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.82 / $1,950.00 / $2,008.50
| Professional | | $244.82 | $1,950.00 | $2,008.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.64 / $1,305.96 / $2,270.90
| Professional | | $870.64 | $1,305.96 | $2,270.90 |