- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.04 / $1,725.04 / $2,070.05
| Facility | | $1,725.04 | $1,725.04 | $2,070.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,742.70
| Professional | | $1,452.25 | $1,452.25 | $1,742.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.05 / $1,452.25 / $1,452.25
| Facility | | $1,370.05 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $2,107.80
| Professional | | $1,452.25 | $1,452.25 | $2,107.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $3,485.40
| Professional | | $1,452.25 | $1,452.25 | $3,485.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.87 / $262.76 / $334.42
| Professional | | $238.87 | $262.76 | $334.42 |