- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,679.35 / $3,679.35 / $5,739.79
| Facility | | $3,679.35 | $3,679.35 | $5,739.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.42 / $3,679.35 / $3,679.35
| Professional | | $3,311.42 | $3,679.35 | $3,679.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,715.94 / $2,715.94 / $2,715.94
| Facility | | $2,715.94 | $2,715.94 | $2,715.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,580.14 / $2,715.94 / $3,020.94
| Professional | | $2,580.14 | $2,715.94 | $3,020.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,265.71 / $4,720.18 / $8,714.25
| Professional | | $2,265.71 | $4,720.18 | $8,714.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,679.35 / $3,679.35 / $6,760.81
| Facility | | $3,679.35 | $3,679.35 | $6,760.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,679.35 / $3,718.08 / $4,647.60
| Professional | | $3,679.35 | $3,718.08 | $4,647.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $3,873.00
| Professional | | $1,626.66 | $2,323.80 | $3,873.00 |