- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,362.23 / $2,507.60 / $3,561.52
| Facility | | $2,362.23 | $2,507.60 | $3,561.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,362.23 / $2,507.60 / $3,634.20
| Professional | | $2,362.23 | $2,507.60 | $3,634.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,804.28 / $6,499.04 / $9,135.29
| Facility | | $3,804.28 | $6,499.04 | $9,135.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,594.39 / $3,103.24 / $3,103.24
| Professional | | $2,594.39 | $3,103.24 | $3,103.24 |
- 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
- $3,523.90 / $3,523.90 / $3,523.90
| Facility | | $3,523.90 | $3,523.90 | $3,523.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.44 / $3,523.90 / $3,523.90
| Professional | | $2,572.44 | $3,523.90 | $3,523.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.68 / $2,266.41 / $3,360.12
| Professional | | $1,453.68 | $2,266.41 | $3,360.12 |