- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,766.79 / $2,937.05 / $4,171.47
| Facility | | $2,766.79 | $2,937.05 | $4,171.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,241.32 / $2,937.05 / $4,256.60
| Professional | | $2,241.32 | $2,937.05 | $4,256.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,455.81 / $7,612.08 / $10,699.82
| Facility | | $4,455.81 | $7,612.08 | $10,699.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,038.71 / $3,634.70 / $3,634.70
| Professional | | $3,038.71 | $3,634.70 | $3,634.70 |
- 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
- $3,294.10 / $3,294.10 / $3,294.10
| Facility | | $3,294.10 | $3,294.10 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $3,294.10 / $3,294.10
| Professional | | $2,404.69 | $3,294.10 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.96 / $2,553.96 / $3,497.15
| Professional | | $1,512.96 | $2,553.96 | $3,497.15 |