- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,049.48 / $4,049.48 / $4,859.38
| Facility | | $4,049.48 | $4,049.48 | $4,859.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,729.12 / $3,142.30 / $4,049.48
| Professional | | $2,729.12 | $3,142.30 | $4,049.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,191.84 / $7,191.84 / $8,525.20
| Facility | | $7,191.84 | $7,191.84 | $8,525.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,670.43 / $3,670.43 / $3,899.83
| Professional | | $3,670.43 | $3,670.43 | $3,899.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,728.96 / $4,728.96 / $4,728.96
| Facility | | $4,728.96 | $4,728.96 | $4,728.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $3,452.14 / $4,870.83
| Professional | | $3,452.14 | $3,452.14 | $4,870.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,822.91 / $5,822.91 / $17,972.41
| Professional | | $5,822.91 | $5,822.91 | $17,972.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,391.94 / $3,587.93 / $5,730.26
| Professional | | $2,391.94 | $3,587.93 | $5,730.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,386.44 / $5,925.08 / $7,541.02
| Professional | | $5,386.44 | $5,925.08 | $7,541.02 |