- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,556.56 / $1,652.34 / $2,346.81
| Facility | | $1,556.56 | $1,652.34 | $2,346.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.57 / $1,652.34 / $2,394.69
| Professional | | $1,310.57 | $1,652.34 | $2,394.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,506.77 / $4,282.43 / $6,019.56
| Facility | | $2,506.77 | $4,282.43 | $6,019.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.53 / $2,044.82 / $2,044.82
| Professional | | $1,709.53 | $2,044.82 | $2,044.82 |
- 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
- $1,552.76 / $1,552.76 / $1,552.76
| Facility | | $1,552.76 | $1,552.76 | $1,552.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.51 / $1,133.51 / $3,519.75
| Professional | | $1,133.51 | $1,133.51 | $3,519.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.48 / $1,436.82 / $1,910.37
| Professional | | $826.48 | $1,436.82 | $1,910.37 |