- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,835.79 / $2,835.79 / $3,002.53
| Facility | | $2,835.79 | $2,835.79 | $3,002.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,914.35 / $2,711.58 / $3,553.33
| Professional | | $1,914.35 | $2,711.58 | $3,553.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,038.29 / $3,038.29 / $3,038.29
| Facility | | $3,038.29 | $3,038.29 | $3,038.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,879.11 / $3,481.20 / $3,593.34
| Professional | | $2,879.11 | $3,481.20 | $3,593.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $3,165.30
| Facility | | $2,200.00 | $2,200.00 | $3,165.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.00 / $2,200.00 / $4,104.00
| Professional | | $1,870.00 | $2,200.00 | $4,104.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.44 / $2,351.37 / $3,772.30
| Professional | | $1,752.44 | $2,351.37 | $3,772.30 |