- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,879.97 / $4,879.97 / $6,739.02
| Facility | | $4,879.97 | $4,879.97 | $6,739.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.80 / $3,756.81 / $4,879.97
| Professional | | $2,323.80 | $3,756.81 | $4,879.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,415.22 / $4,415.22 / $4,415.22
| Facility | | $4,415.22 | $4,415.22 | $4,415.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,485.70 / $5,809.50 / $5,809.50
| Professional | | $3,485.70 | $5,809.50 | $5,809.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,517.44 / $2,920.24 / $6,948.16
| Facility | | $2,517.44 | $2,920.24 | $6,948.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.89 / $3,330.65 / $5,781.37
| Professional | | $1,763.89 | $3,330.65 | $5,781.37 |
- 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 |