- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,456.12 / $2,607.27 / $3,703.08
| Facility | | $2,456.12 | $2,607.27 | $3,703.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,106.14 / $2,607.27 / $3,778.65
| Professional | | $2,106.14 | $2,607.27 | $3,778.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,955.49 / $6,757.36 / $9,498.39
| Facility | | $3,955.49 | $6,757.36 | $9,498.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,697.51 / $3,226.58 / $3,226.58
| Professional | | $2,697.51 | $3,226.58 | $3,226.58 |
- 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
- $2,728.17 / $2,728.17 / $2,728.17
| Facility | | $2,728.17 | $2,728.17 | $2,728.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $5,087.25
| Professional | | $1,991.56 | $1,991.56 | $5,087.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.72 / $2,267.19 / $3,048.16
| Professional | | $1,318.72 | $2,267.19 | $3,048.16 |