- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,139.85 / $4,139.85 / $4,967.82
| Facility | | $4,139.85 | $4,139.85 | $4,967.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,209.83 / $3,284.26 / $4,139.85
| Professional | | $3,209.83 | $3,284.26 | $4,139.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,352.35 / $7,352.35 / $8,715.48
| Facility | | $7,352.35 | $7,352.35 | $8,715.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,971.24 / $3,971.24 / $4,148.14
| Professional | | $3,971.24 | $3,971.24 | $4,148.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,423.18 / $4,423.18 / $4,423.18
| Facility | | $4,423.18 | $4,423.18 | $4,423.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,228.92 / $3,228.92 / $4,423.18
| Professional | | $3,228.92 | $3,228.92 | $4,423.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,952.87 / $5,952.87 / $18,373.53
| Professional | | $5,952.87 | $5,952.87 | $18,373.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,445.34 / $3,668.01 / $4,885.06
| Professional | | $2,445.34 | $3,668.01 | $4,885.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,506.67 / $6,057.34 / $7,709.34
| Professional | | $5,506.67 | $6,057.34 | $7,709.34 |