- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,005.64 / $2,005.64 / $2,005.64
| Facility | | $2,005.64 | $2,005.64 | $2,005.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.64 / $2,005.64 / $2,042.77
| Professional | | $2,005.64 | $2,005.64 | $2,042.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.73 / $58.73 / $85.09
| Facility | | $43.73 | $58.73 | $85.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Facility | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.75 / $2,039.14 / $2,039.14
| Professional | | $1,202.75 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $719.87 / $2,005.64 / $2,868.07
| Facility | | $719.87 | $2,005.64 | $2,868.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.52 / $2,123.77 / $2,250.34
| Professional | | $1,781.52 | $2,123.77 | $2,250.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.52 / $2,123.77 / $2,250.34
| Professional | | $1,781.52 | $2,123.77 | $2,250.34 |