- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,577.17 / $1,805.19 / $2,460.39
| Facility | | $1,577.17 | $1,805.19 | $2,460.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,577.17 / $1,805.19 / $1,805.19
| Professional | | $1,577.17 | $1,805.19 | $1,805.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,332.52 / $1,332.52 / $1,332.52
| Facility | | $1,332.52 | $1,332.52 | $1,332.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.89 / $1,332.52 / $1,482.16
| Professional | | $1,265.89 | $1,332.52 | $1,482.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.21 / $1,900.21 / $2,375.26
| Professional | | $1,900.21 | $1,900.21 | $2,375.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,624.67 / $1,805.19 / $2,898.05
| Facility | | $1,624.67 | $1,805.19 | $2,898.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.19 / $1,824.19 / $2,280.23
| Professional | | $1,805.19 | $1,824.19 | $2,280.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.08 / $1,140.11 / $1,900.20
| Professional | | $798.08 | $1,140.11 | $1,900.20 |