- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,999.95 / $2,123.03 / $3,015.31
| Facility | | $1,999.95 | $2,123.03 | $3,015.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,951.62 / $2,123.03 / $3,076.85
| Professional | | $1,951.62 | $2,123.03 | $3,076.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,220.85 / $5,502.33 / $7,734.28
| Facility | | $3,220.85 | $5,502.33 | $7,734.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,196.50 / $2,627.32 / $2,627.32
| Professional | | $2,196.50 | $2,627.32 | $2,627.32 |
- 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
- $2,717.61 / $2,717.61 / $2,717.61
| Facility | | $2,717.61 | $2,717.61 | $2,717.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $2,717.61 / $2,717.61
| Professional | | $1,983.86 | $2,717.61 | $2,717.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.74 / $1,918.83 / $2,844.80
| Professional | | $1,230.74 | $1,918.83 | $2,844.80 |