- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,092.94 / $3,283.28 / $4,663.20
| Facility | | $3,092.94 | $3,283.28 | $4,663.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,770.81 / $3,283.28 / $4,758.37
| Professional | | $2,770.81 | $3,283.28 | $4,758.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,981.06 / $8,509.39 / $11,961.11
| Facility | | $4,981.06 | $8,509.39 | $11,961.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,396.89 / $4,063.16 / $4,063.16
| Professional | | $3,396.89 | $4,063.16 | $4,063.16 |
- 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
- $3,728.42 / $3,728.42 / $3,728.42
| Facility | | $3,728.42 | $3,728.42 | $3,728.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $3,728.42 / $3,728.42
| Professional | | $2,721.75 | $3,728.42 | $3,728.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.34 / $2,855.02 / $4,113.26
| Professional | | $1,708.34 | $2,855.02 | $4,113.26 |