- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,403.08 / $2,550.96 / $3,623.10
| Facility | | $2,403.08 | $2,550.96 | $3,623.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.68 / $2,550.96 / $3,697.04
| Professional | | $1,946.68 | $2,550.96 | $3,697.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,870.06 / $6,611.42 / $9,293.25
| Facility | | $3,870.06 | $6,611.42 | $9,293.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,639.24 / $3,156.89 / $3,156.89
| Professional | | $2,639.24 | $3,156.89 | $3,156.89 |
- 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
- $3,060.59 / $3,060.59 / $3,060.59
| Facility | | $3,060.59 | $3,060.59 | $3,060.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.23 / $2,234.23 / $5,127.38
| Professional | | $2,234.23 | $2,234.23 | $5,127.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.07 / $2,218.21 / $3,126.16
| Professional | | $1,314.07 | $2,218.21 | $3,126.16 |