- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,071.43 / $5,383.53 / $7,646.18
| Facility | | $5,071.43 | $5,383.53 | $7,646.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,825.46 / $5,383.53 / $7,802.22
| Professional | | $3,825.46 | $5,383.53 | $7,802.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,167.36 / $13,952.71 / $19,612.43
| Facility | | $8,167.36 | $13,952.71 | $19,612.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,569.85 / $6,662.29 / $6,662.29
| Professional | | $5,569.85 | $6,662.29 | $6,662.29 |
- 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
- $4,697.47 / $4,697.47 / $4,697.47
| Facility | | $4,697.47 | $4,697.47 | $4,697.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $3,429.16 / $8,418.37
| Professional | | $3,429.16 | $3,429.16 | $8,418.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.66 / $4,681.33 / $5,630.11
| Professional | | $2,340.66 | $4,681.33 | $5,630.11 |