- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,924.00 / $6,375.78 / $8,079.01
| Facility | | $2,924.00 | $6,375.78 | $8,079.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,924.00 / $2,924.00 / $4,907.06
| Professional | | $2,924.00 | $2,924.00 | $4,907.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,805.00 / $2,805.00 / $3,506.25
| Professional | | $2,805.00 | $2,805.00 | $3,506.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,163.15 / $3,400.00 / $15,731.30
| Facility | | $3,163.15 | $3,400.00 | $15,731.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.83 / $3,045.83 / $3,728.10
| Professional | | $3,045.83 | $3,045.83 | $3,728.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,739.26 / $5,553.15 / $7,457.09
| Facility | | $4,739.26 | $5,553.15 | $7,457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,402.80 / $3,402.80 / $3,402.80
| Professional | | $3,402.80 | $3,402.80 | $3,402.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,893.54 / $3,045.83 / $3,350.41
| Professional | | $2,893.54 | $3,045.83 | $3,350.41 |