- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,371.42 / $2,517.35 / $3,575.37
| Facility | | $2,371.42 | $2,517.35 | $3,575.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,106.84 / $2,517.35 / $3,648.34
| Professional | | $2,106.84 | $2,517.35 | $3,648.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,819.08 / $6,524.33 / $9,170.83
| Facility | | $3,819.08 | $6,524.33 | $9,170.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,604.48 / $3,115.31 / $3,115.31
| Professional | | $2,604.48 | $3,115.31 | $3,115.31 |
- 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
- $3,600.52 / $3,600.52 / $3,600.52
| Facility | | $3,600.52 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.44 / $3,600.52 / $3,600.52
| Professional | | $3,060.44 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.50 / $2,220.08 / $3,205.69
| Professional | | $1,347.50 | $2,220.08 | $3,205.69 |