- 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
- $3,141.78 / $4,380.93 / $7,694.39
| Facility | | $3,141.78 | $4,380.93 | $7,694.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,759.51 / $2,904.75 / $3,108.08
| Professional | | $2,759.51 | $2,904.75 | $3,108.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,714.90 / $2,168.88 / $5,900.23
| Professional | | $1,714.90 | $2,168.88 | $5,900.23 |
- 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
- $3,206.84 / $3,527.52 / $5,772.31
| Professional | | $3,206.84 | $3,527.52 | $5,772.31 |
- 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 |