- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.62 / $1,576.31 / $1,732.80
| Facility | | $1,530.62 | $1,576.31 | $1,732.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.62 / $1,576.31 / $1,700.15
| Professional | | $1,530.62 | $1,576.31 | $1,700.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.15 / $1,750.77 / $2,561.83
| Professional | | $1,599.15 | $1,750.77 | $2,561.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.33 / $303.33 / $303.33
| Facility | | $303.33 | $303.33 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $257.83 / $3,609.38
| Professional | | $192.51 | $257.83 | $3,609.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.68 / $180.68 / $180.68
| Professional | | $180.68 | $180.68 | $180.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.71 / $209.86 / $1,299.59
| Professional | | $129.71 | $209.86 | $1,299.59 |