- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,303.92 / $4,887.04 / $5,003.52
| Facility | | $3,303.92 | $4,887.04 | $5,003.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,303.92 / $3,785.74 / $6,883.16
| Professional | | $3,303.92 | $3,785.74 | $6,883.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,702.76 / $3,906.15 / $6,016.61
| Professional | | $3,702.76 | $3,906.15 | $6,016.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,063.89 / $4,063.89 / $4,063.89
| Facility | | $4,063.89 | $4,063.89 | $4,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.31 / $3,454.31 / $4,185.81
| Professional | | $3,454.31 | $3,454.31 | $4,185.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,303.92 / $5,828.11 / $31,266.85
| Facility | | $3,303.92 | $5,828.11 | $31,266.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,703.86 / $3,865.58 / $6,528.92
| Professional | | $2,703.86 | $3,865.58 | $6,528.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,703.86 / $3,607.77 / $5,348.22
| Professional | | $2,703.86 | $3,607.77 | $5,348.22 |