- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,578.50 / $4,860.26 / $6,902.97
| Facility | | $4,578.50 | $4,860.26 | $6,902.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,209.08 / $4,860.26 / $7,043.85
| Professional | | $4,209.08 | $4,860.26 | $7,043.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,373.50 / $12,596.52 / $17,706.13
| Facility | | $7,373.50 | $12,596.52 | $17,706.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,028.47 / $6,014.72 / $6,014.72
| Professional | | $5,028.47 | $6,014.72 | $6,014.72 |
- 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
- $4,751.45 / $4,751.45 / $4,751.45
| Facility | | $4,751.45 | $4,751.45 | $4,751.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,038.73 / $4,751.45 / $4,751.45
| Professional | | $4,038.73 | $4,751.45 | $4,751.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.05 / $4,226.31 / $6,366.34
| Professional | | $2,529.05 | $4,226.31 | $6,366.34 |