- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,556.33 / $2,556.33 / $2,556.33
| Facility | | $2,556.33 | $2,556.33 | $2,556.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,321.98 / $2,554.17 / $2,556.33
| Professional | | $2,321.98 | $2,554.17 | $2,556.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.06 / $207.13 / $366.26
| Professional | | $176.06 | $207.13 | $366.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,039.21 / $1,426.36 / $1,645.42
| Facility | | $1,039.21 | $1,426.36 | $1,645.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.46 / $1,411.57 / $2,037.66
| Professional | | $1,133.46 | $1,411.57 | $2,037.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,335.43 / $1,335.43 / $1,335.43
| Facility | | $1,335.43 | $1,335.43 | $1,335.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,597.18 / $5,597.18 / $5,597.18
| Professional | | $5,597.18 | $5,597.18 | $5,597.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $45.00
| Professional | | $45.00 | $45.00 | $45.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.94 / $1,189.75 / $1,730.46
| Professional | | $990.94 | $1,189.75 | $1,730.46 |