- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,994.00 / $1,994.00 / $1,997.67
| Facility | | $1,994.00 | $1,994.00 | $1,997.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.55 / $1,840.73 / $2,214.19
| Professional | | $1,773.55 | $1,840.73 | $2,214.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.97 / $53.13 / $1,757.29
| Professional | | $37.97 | $53.13 | $1,757.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,022.40 / $2,325.76 / $3,033.60
| Facility | | $2,022.40 | $2,325.76 | $3,033.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,723.61 / $2,723.61 / $2,723.61
| Professional | | $2,723.61 | $2,723.61 | $2,723.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,373.25 / $2,490.73 / $2,984.18
| Professional | | $2,373.25 | $2,490.73 | $2,984.18 |