- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,682.56 / $2,847.64 / $3,836.06
| Facility | | $2,682.56 | $2,847.64 | $3,836.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,357.35 / $2,847.64 / $3,095.26
| Professional | | $2,357.35 | $2,847.64 | $3,095.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,320.14 / $7,380.33 / $10,374.07
| Facility | | $4,320.14 | $7,380.33 | $10,374.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,946.19 / $3,524.04 / $3,524.04
| Professional | | $2,946.19 | $3,524.04 | $3,524.04 |
- 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
- $2,756.64 / $2,756.64 / $2,756.64
| Facility | | $2,756.64 | $2,756.64 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $5,723.63
| Professional | | $2,012.35 | $2,012.35 | $5,723.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.28 / $2,330.85 / $3,490.64
| Professional | | $1,467.28 | $2,330.85 | $3,490.64 |