- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,627.04 / $1,727.17 / $2,453.08
| Facility | | $1,627.04 | $1,727.17 | $2,453.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.93 / $1,727.17 / $2,503.14
| Professional | | $1,471.93 | $1,727.17 | $2,503.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,620.29 / $4,476.37 / $6,292.14
| Facility | | $2,620.29 | $4,476.37 | $6,292.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.94 / $2,137.42 / $2,137.42
| Professional | | $1,786.94 | $2,137.42 | $2,137.42 |
- 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
- $2,125.02 / $2,125.02 / $2,125.02
| Facility | | $2,125.02 | $2,125.02 | $2,125.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.26 / $2,125.02 / $2,125.02
| Professional | | $1,551.26 | $2,125.02 | $2,125.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.28 / $1,530.95 / $2,141.06
| Professional | | $926.28 | $1,530.95 | $2,141.06 |