- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.87 / $1,732.80 / $1,740.32
| Facility | | $1,689.87 | $1,732.80 | $1,740.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,689.87 / $1,740.32 / $2,062.98
| Professional | | $1,689.87 | $1,740.32 | $2,062.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.98 / $1,765.54 / $2,496.60
| Professional | | $1,751.98 | $1,765.54 | $2,496.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $1,472.88 / $3,637.50
| Professional | | $192.51 | $1,472.88 | $3,637.50 |
- 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
- $143.24 / $254.65 / $1,867.01
| Professional | | $143.24 | $254.65 | $1,867.01 |