- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,744.82 / $1,852.19 / $2,495.09
| Facility | | $1,744.82 | $1,852.19 | $2,495.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,721.81 / $1,852.19 / $2,013.26
| Professional | | $1,721.81 | $1,852.19 | $2,013.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,809.97 / $4,800.41 / $6,747.63
| Facility | | $2,809.97 | $4,800.41 | $6,747.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.30 / $2,292.16 / $2,292.16
| Professional | | $1,916.30 | $2,292.16 | $2,292.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Facility | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.28 / $2,017.28 / $2,017.28
| Facility | | $2,017.28 | $2,017.28 | $2,017.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.61 / $2,017.28 / $2,017.28
| Professional | | $1,472.61 | $2,017.28 | $2,017.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.74 / $1,532.65 / $2,464.66
| Professional | | $1,073.74 | $1,532.65 | $2,464.66 |