- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,253.51 / $2,392.19 / $3,397.60
| Facility | | $2,253.51 | $2,392.19 | $3,397.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,253.51 / $2,392.19 / $3,466.94
| Professional | | $2,253.51 | $2,392.19 | $3,466.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,629.19 / $6,199.93 / $8,714.85
| Facility | | $3,629.19 | $6,199.93 | $8,714.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,474.96 / $2,960.40 / $2,960.40
| Professional | | $2,474.96 | $2,960.40 | $2,960.40 |
- 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
- $3,006.81 / $3,006.81 / $3,006.81
| Facility | | $3,006.81 | $3,006.81 | $3,006.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.96 / $3,006.81 / $3,006.81
| Professional | | $2,194.96 | $3,006.81 | $3,006.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.78 / $2,162.09 / $3,343.20
| Professional | | $1,386.78 | $2,162.09 | $3,343.20 |