- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,904.77 / $3,904.77 / $4,367.77
| Facility | | $3,904.77 | $3,904.77 | $4,367.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,859.41 / $2,183.88 / $2,987.15
| Professional | | $1,859.41 | $2,183.88 | $2,987.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,861.64 / $2,861.64 / $2,861.64
| Facility | | $2,861.64 | $2,861.64 | $2,861.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.21 / $4,183.68 / $4,183.68
| Professional | | $2,510.21 | $4,183.68 | $4,183.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.64 / $3,238.01 / $5,228.93
| Facility | | $1,631.64 | $3,238.01 | $5,228.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,158.67 / $2,796.88 / $4,192.57
| Professional | | $2,158.67 | $2,796.88 | $4,192.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,510.21 / $2,510.21
| Facility | | $2,510.21 | $2,510.21 | $2,510.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,549.51 / $3,419.42
| Professional | | $1,054.29 | $1,549.51 | $3,419.42 |