- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,573.23 / $3,756.08 / $3,912.42
| Facility | | $3,573.23 | $3,756.08 | $3,912.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,736.53 / $3,673.81 / $4,562.43
| Professional | | $2,736.53 | $3,673.81 | $4,562.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,327.68 / $4,327.68 / $8,352.44
| Facility | | $4,327.68 | $4,327.68 | $8,352.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,845.65 / $4,327.68 / $4,995.45
| Professional | | $3,845.65 | $4,327.68 | $4,995.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $3,684.93
| Facility | | $200.00 | $200.00 | $3,684.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.00 / $3,344.98 / $6,495.00
| Professional | | $462.00 | $3,344.98 | $6,495.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,174.85 / $2,899.80 / $5,142.10
| Professional | | $2,174.85 | $2,899.80 | $5,142.10 |