- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,677.35 / $7,762.47
| Facility | | $3,981.07 | $4,677.35 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $3,801.89
| Professional | | $2,884.03 | $3,019.95 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,981.07
| Facility | | $3,090.30 | $3,090.30 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $11,481.54 / $25,703.96
| Facility | | $5,011.87 | $11,481.54 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $4,570.88
| Facility | | $2,570.40 | $3,388.44 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,467.37
| Professional | | $3,019.95 | $3,019.95 | $3,467.37 |