- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,068.04 / $5,068.04 / $5,149.24
| Facility | | $5,068.04 | $5,068.04 | $5,149.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,727.70 / $4,707.08 / $5,981.27
| Professional | | $3,727.70 | $4,707.08 | $5,981.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,592.27 / $7,890.52 / $7,890.52
| Facility | | $4,592.27 | $7,890.52 | $7,890.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,731.63 / $3,917.60 / $4,916.00
| Professional | | $3,731.63 | $3,917.60 | $4,916.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,587.01 / $5,587.01 / $5,587.01
| Facility | | $5,587.01 | $5,587.01 | $5,587.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.31 / $5,587.01 / $6,653.09
| Professional | | $665.31 | $5,587.01 | $6,653.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,037.94 / $2,854.88 / $4,640.68
| Professional | | $2,037.94 | $2,854.88 | $4,640.68 |