- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,795.88 / $7,018.36 / $7,018.36
| Facility | | $4,795.88 | $7,018.36 | $7,018.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,678.89 / $4,854.35 / $7,018.36
| Professional | | $4,678.89 | $4,854.35 | $7,018.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,216.00 / $3,216.00 / $3,537.60
| Facility | | $3,216.00 | $3,216.00 | $3,537.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,456.00 / $3,456.00 / $4,306.10
| Professional | | $3,456.00 | $3,456.00 | $4,306.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,971.34 / $4,971.34 / $4,971.34
| Facility | | $4,971.34 | $4,971.34 | $4,971.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,755.74 / $4,971.34 / $4,971.34
| Professional | | $4,755.74 | $4,971.34 | $4,971.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $5,166.29
| Professional | | $1,000.00 | $1,000.00 | $5,166.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,386.47 / $4,873.85 / $6,238.54
| Professional | | $4,386.47 | $4,873.85 | $6,238.54 |