- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.36 / $3,061.86 / $4,348.72
| Facility | | $2,884.36 | $3,061.86 | $4,348.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.36 / $3,061.86 / $4,437.47
| Professional | | $2,884.36 | $3,061.86 | $4,437.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,645.14 / $7,935.55 / $11,154.49
| Facility | | $4,645.14 | $7,935.55 | $11,154.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,167.83 / $3,789.15 / $3,789.15
| Professional | | $3,167.83 | $3,789.15 | $3,789.15 |
- 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
- $4,072.36 / $4,072.36 / $4,072.36
| Facility | | $4,072.36 | $4,072.36 | $4,072.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $4,072.36 / $4,072.36
| Professional | | $2,972.82 | $4,072.36 | $4,072.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,774.99 / $2,662.49 / $4,102.81
| Professional | | $1,774.99 | $2,662.49 | $4,102.81 |