- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,703.36 / $2,869.72 / $4,075.84
| Facility | | $2,703.36 | $2,869.72 | $4,075.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,408.08 / $2,869.72 / $4,159.02
| Professional | | $2,408.08 | $2,869.72 | $4,159.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,353.66 / $7,437.58 / $10,454.53
| Facility | | $4,353.66 | $7,437.58 | $10,454.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,969.04 / $3,551.37 / $3,551.37
| Professional | | $2,969.04 | $3,551.37 | $3,551.37 |
- 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
- $2,853.06 / $2,853.06 / $2,853.06
| Facility | | $2,853.06 | $2,853.06 | $2,853.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,853.06 / $2,853.06
| Professional | | $2,082.73 | $2,853.06 | $2,853.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.59 / $2,543.71 / $3,510.16
| Professional | | $1,518.59 | $2,543.71 | $3,510.16 |