- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,109.46 / $7,522.72 / $7,522.72
| Facility | | $4,109.46 | $7,522.72 | $7,522.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,850.00 / $2,850.00 / $3,175.86
| Professional | | $2,850.00 | $2,850.00 | $3,175.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,419.42 / $4,561.62 / $4,957.43
| Facility | | $3,419.42 | $4,561.62 | $4,957.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,469.04 / $2,904.75 / $2,904.75
| Professional | | $2,469.04 | $2,904.75 | $2,904.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,991.61 / $5,991.61 / $10,532.88
| Facility | | $5,991.61 | $5,991.61 | $10,532.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,956.20 / $5,139.59 / $10,483.77
| Professional | | $1,956.20 | $5,139.59 | $10,483.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $5,911.04
| Professional | | $1,626.66 | $2,323.80 | $5,911.04 |