- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $5,623.41
| Facility | | $4,073.80 | $4,073.80 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,630.27 / $4,073.80
| Professional | | $2,137.96 | $2,630.27 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $5,011.87
| Facility | | $3,630.78 | $3,630.78 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,897.79 / $4,897.79
| Professional | | $3,311.31 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,981.07 / $6,025.60
| Facility | | $2,089.30 | $3,981.07 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,467.37 / $4,897.79
| Professional | | $2,818.38 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,235.94
| Facility | | $2,884.03 | $2,884.03 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,698.24 / $3,019.95
| Professional | | $1,348.96 | $1,698.24 | $3,019.95 |