- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,225.82 / $4,225.82 / $4,463.61
| Facility | | $4,225.82 | $4,225.82 | $4,463.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,781.67 / $3,881.40 / $5,029.47
| Professional | | $2,781.67 | $3,881.40 | $5,029.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,230.41 / $4,230.41 / $4,230.41
| Facility | | $4,230.41 | $4,230.41 | $4,230.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,134.60 / $5,097.37 / $5,415.20
| Professional | | $4,134.60 | $5,097.37 | $5,415.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $4,653.68
| Facility | | $2,900.00 | $2,900.00 | $4,653.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.00 / $2,900.00 / $5,213.36
| Professional | | $2,465.00 | $2,900.00 | $5,213.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,220.54 / $2,886.70 / $4,571.13
| Professional | | $2,220.54 | $2,886.70 | $4,571.13 |