- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,216.58 / $2,363.60 / $3,687.22
| Facility | | $2,216.58 | $2,363.60 | $3,687.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,127.23 / $2,954.50 / $3,732.00
| Professional | | $2,127.23 | $2,954.50 | $3,732.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,657.47 / $1,657.47 / $1,744.71
| Facility | | $1,657.47 | $1,657.47 | $1,744.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.47 / $1,744.71 / $2,355.36
| Professional | | $1,657.47 | $1,744.71 | $2,355.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.20 / $3,032.25 / $3,790.31
| Professional | | $2,859.20 | $3,032.25 | $3,790.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,363.60 / $2,363.60 / $4,343.12
| Facility | | $2,363.60 | $2,363.60 | $4,343.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,388.48 / $2,388.48 / $2,985.60
| Professional | | $2,388.48 | $2,388.48 | $2,985.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.96 / $1,492.80 / $2,488.00
| Professional | | $1,044.96 | $1,492.80 | $2,488.00 |