- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,396.74 / $1,632.20 / $2,632.68
| Facility | | $1,396.74 | $1,632.20 | $2,632.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.40 / $1,097.40 / $2,230.04
| Professional | | $576.40 | $1,097.40 | $2,230.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,404.55 / $2,404.55 / $2,404.55
| Facility | | $2,404.55 | $2,404.55 | $2,404.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.00 / $2,776.00 / $2,776.00
| Professional | | $1,906.00 | $2,776.00 | $2,776.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $58.40 / $58.40
| Professional | | $58.40 | $58.40 | $58.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,404.55 / $2,404.55 / $2,404.55
| Facility | | $2,404.55 | $2,404.55 | $2,404.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.62 / $2,776.00 / $2,776.00
| Professional | | $920.62 | $2,776.00 | $2,776.00 |