- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,812.67 / $4,812.67 / $5,095.92
| Facility | | $4,812.67 | $4,812.67 | $5,095.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.86 / $4,539.64 / $5,697.07
| Professional | | $3,859.86 | $4,539.64 | $5,697.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,774.00 / $9,204.04 / $9,204.04
| Facility | | $7,774.00 | $9,204.04 | $9,204.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,742.92 / $5,560.00 / $5,723.24
| Professional | | $4,742.92 | $5,560.00 | $5,723.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $4,775.22
| Facility | | $4,775.22 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.53 / $4,775.22 / $7,155.14
| Professional | | $671.53 | $4,775.22 | $7,155.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,947.05 / $3,853.26 / $6,401.20
| Professional | | $2,947.05 | $3,853.26 | $6,401.20 |