- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,803.02 / $1,837.43 / $1,837.43
| Facility | | $1,803.02 | $1,837.43 | $1,837.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.55 / $1,825.83 / $2,117.23
| Professional | | $1,773.55 | $1,825.83 | $2,117.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.00 / $60.00 / $64.00
| Facility | | $15.00 | $60.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.96 / $58.27 / $1,757.11
| Professional | | $45.96 | $58.27 | $1,757.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,373.25 / $2,490.73 / $2,984.18
| Professional | | $2,373.25 | $2,490.73 | $2,984.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,022.40 / $2,022.40 / $2,022.40
| Facility | | $2,022.40 | $2,022.40 | $2,022.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,022.40 / $2,022.40 / $2,022.40
| Professional | | $2,022.40 | $2,022.40 | $2,022.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.00 / $555.00 / $597.00
| Facility | | $555.00 | $555.00 | $597.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,373.25 / $2,490.73 / $2,984.18
| Professional | | $2,373.25 | $2,490.73 | $2,984.18 |