- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,117.36 / $2,247.65 / $3,192.32
| Facility | | $2,117.36 | $2,247.65 | $3,192.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,881.10 / $2,247.65 / $3,257.47
| Professional | | $1,881.10 | $2,247.65 | $3,257.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,409.92 / $5,825.33 / $8,188.30
| Facility | | $3,409.92 | $5,825.33 | $8,188.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,325.44 / $2,781.54 / $2,781.54
| Professional | | $2,325.44 | $2,781.54 | $2,781.54 |
- 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
- $3,214.74 / $3,214.74 / $3,214.74
| Facility | | $3,214.74 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $3,214.74 / $3,214.74
| Professional | | $2,732.53 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.11 / $1,954.48 / $2,780.96
| Professional | | $1,203.11 | $1,954.48 | $2,780.96 |