- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,681.60 / $2,846.62 / $4,043.03
| Facility | | $2,681.60 | $2,846.62 | $4,043.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,172.31 / $2,846.62 / $4,125.54
| Professional | | $2,172.31 | $2,846.62 | $4,125.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,318.62 / $7,377.70 / $10,370.37
| Facility | | $4,318.62 | $7,377.70 | $10,370.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,945.14 / $3,522.79 / $3,522.79
| Professional | | $2,945.14 | $3,522.79 | $3,522.79 |
- 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
- $2,801.20 / $2,801.20 / $2,801.20
| Facility | | $2,801.20 | $2,801.20 | $2,801.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.88 / $2,044.88 / $5,721.75
| Professional | | $2,044.88 | $2,044.88 | $5,721.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.37 / $2,475.32 / $3,389.45
| Professional | | $1,466.37 | $2,475.32 | $3,389.45 |