- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,818.38 / $4,073.80
| Professional | | $2,398.83 | $2,818.38 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,888.44 / $7,413.10
| Facility | | $3,548.13 | $5,888.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,548.13 / $6,165.95
| Professional | | $1,023.29 | $3,548.13 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,918.31 / $8,317.64
| Facility | | $5,495.41 | $6,918.31 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $5,888.44
| Facility | | $2,454.71 | $3,715.35 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $5,011.87
| Professional | | $2,691.53 | $2,691.53 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,073.80 / $4,570.88
| Facility | | $3,388.44 | $4,073.80 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,884.03 / $4,365.16
| Professional | | $1,698.24 | $2,884.03 | $4,365.16 |