- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,207.79 / $2,343.65 / $3,328.67
| Facility | | $2,207.79 | $2,343.65 | $3,328.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.48 / $2,343.65 / $3,396.60
| Professional | | $1,788.48 | $2,343.65 | $3,396.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,555.56 / $6,074.14 / $8,538.03
| Facility | | $3,555.56 | $6,074.14 | $8,538.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,424.77 / $2,900.34 / $2,900.34
| Professional | | $2,424.77 | $2,900.34 | $2,900.34 |
- 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
- $2,282.71 / $2,282.71 / $2,282.71
| Facility | | $2,282.71 | $2,282.71 | $2,282.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.39 / $1,666.39 / $4,710.75
| Professional | | $1,666.39 | $1,666.39 | $4,710.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.23 / $1,982.23 / $1,982.23
| Facility | | $1,982.23 | $1,982.23 | $1,982.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.02 / $2,118.23 / $3,005.38
| Professional | | $1,215.02 | $2,118.23 | $3,005.38 |