- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,926.16 / $3,926.16 / $5,421.84
| Facility | | $3,926.16 | $3,926.16 | $5,421.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.44 / $3,022.52 / $3,926.16
| Professional | | $1,875.44 | $3,022.52 | $3,926.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,178.32 / $4,674.00 / $4,674.00
| Professional | | $3,178.32 | $4,674.00 | $4,674.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,025.40 / $4,019.56 / $4,658.42
| Facility | | $2,025.40 | $4,019.56 | $4,658.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.71 / $3,124.67 / $4,684.09
| Professional | | $2,679.71 | $3,124.67 | $4,684.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,804.40 / $2,804.40 / $2,804.40
| Facility | | $2,804.40 | $2,804.40 | $2,804.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.72 / $1,869.60 / $3,125.73
| Professional | | $1,308.72 | $1,869.60 | $3,125.73 |