- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,248.26 / $6,248.26 / $6,380.89
| Facility | | $6,248.26 | $6,248.26 | $6,380.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,979.26 / $6,020.75 / $7,466.38
| Professional | | $3,979.26 | $6,020.75 | $7,466.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,215.00 / $2,867.09 / $3,306.72
| Facility | | $1,215.00 | $2,867.09 | $3,306.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,396.58 / $7,267.58 / $8,456.90
| Professional | | $5,396.58 | $7,267.58 | $8,456.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,488.00 / $4,978.93 / $4,978.93
| Facility | | $4,488.00 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,232.09 / $4,232.09 / $11,898.75
| Professional | | $4,232.09 | $4,232.09 | $11,898.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,417.69 / $3,413.20 / $5,629.60
| Professional | | $2,417.69 | $3,413.20 | $5,629.60 |