- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,625.51 / $2,787.08 / $3,958.46
| Facility | | $2,625.51 | $2,787.08 | $3,958.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,332.57 / $2,787.08 / $4,039.24
| Professional | | $2,332.57 | $2,787.08 | $4,039.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,228.28 / $7,223.37 / $10,153.44
| Facility | | $4,228.28 | $7,223.37 | $10,153.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,883.54 / $3,449.09 / $3,449.09
| Professional | | $2,883.54 | $3,449.09 | $3,449.09 |
- 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
- $2,802.84 / $2,802.84 / $2,802.84
| Facility | | $2,802.84 | $2,802.84 | $2,802.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.41 / $2,802.84 / $2,802.84
| Professional | | $2,382.41 | $2,802.84 | $2,802.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.86 / $2,423.54 / $3,448.38
| Professional | | $1,491.86 | $2,423.54 | $3,448.38 |