- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.19 / $1,380.19 / $1,637.56
| Facility | | $1,380.19 | $1,380.19 | $1,637.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.57 / $1,398.77 / $1,692.17
| Professional | | $1,348.57 | $1,398.77 | $1,692.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.77 / $2,095.62 / $2,510.79
| Professional | | $1,996.77 | $2,095.62 | $2,510.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.21 / $1,704.50 / $1,714.58
| Professional | | $1,200.21 | $1,704.50 | $1,714.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $50.00 / $2,554.71
| Professional | | $40.00 | $50.00 | $2,554.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.67 / $1,342.67 / $1,342.67
| Professional | | $1,342.67 | $1,342.67 | $1,342.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.67 / $1,342.67 / $1,342.67
| Professional | | $1,342.67 | $1,342.67 | $1,342.67 |