- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $6,456.54
| Facility | | $4,677.35 | $4,677.35 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $4,677.35
| Professional | | $2,454.71 | $3,019.95 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $5,754.40
| Facility | | $4,265.80 | $4,265.80 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,623.41 / $5,623.41
| Professional | | $3,801.89 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,073.80 / $6,918.31
| Facility | | $2,454.71 | $4,073.80 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,981.07 / $5,623.41
| Professional | | $3,235.94 | $3,981.07 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,715.35
| Facility | | $3,388.44 | $3,388.44 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $3,311.31
| Professional | | $1,445.44 | $1,737.80 | $3,311.31 |