- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,823.63 / $2,997.39 / $4,257.17
| Facility | | $2,823.63 | $2,997.39 | $4,257.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.63 / $2,997.39 / $4,344.05
| Professional | | $2,823.63 | $2,997.39 | $4,344.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,547.35 / $7,768.46 / $10,919.64
| Facility | | $4,547.35 | $7,768.46 | $10,919.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,101.12 / $3,709.37 / $3,709.37
| Professional | | $3,101.12 | $3,709.37 | $3,709.37 |
- 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
- $3,745.37 / $3,745.37 / $3,745.37
| Facility | | $3,745.37 | $3,745.37 | $3,745.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $6,712.13
| Professional | | $2,734.12 | $2,734.12 | $6,712.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.35 / $2,709.08 / $4,008.86
| Professional | | $1,734.35 | $2,709.08 | $4,008.86 |