- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,387.83 / $2,534.77 / $3,600.11
| Facility | | $2,387.83 | $2,534.77 | $3,600.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,087.98 / $2,534.77 / $3,673.58
| Professional | | $2,087.98 | $2,534.77 | $3,673.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,845.50 / $6,569.46 / $9,234.28
| Facility | | $3,845.50 | $6,569.46 | $9,234.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,622.50 / $3,136.87 / $3,136.87
| Professional | | $2,622.50 | $3,136.87 | $3,136.87 |
- 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
- $3,001.57 / $3,001.57 / $3,001.57
| Facility | | $3,001.57 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $3,001.57 / $3,001.57
| Professional | | $2,191.15 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.73 / $2,246.80 / $3,246.47
| Professional | | $1,316.73 | $2,246.80 | $3,246.47 |