- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $5,370.32
| Facility | | $3,388.44 | $3,388.44 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,388.44 / $5,370.32
| Professional | | $2,630.27 | $3,388.44 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,073.80
| Facility | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $4,073.80
| Professional | | $2,951.21 | $2,951.21 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,897.79 / $7,585.78
| Facility | | $3,715.35 | $4,897.79 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,884.03 / $4,265.80
| Professional | | $1,862.09 | $2,884.03 | $4,265.80 |