- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,481.52 / $3,481.52 / $4,177.82
| Facility | | $3,481.52 | $3,481.52 | $4,177.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,701.58 / $2,772.72 / $3,481.52
| Professional | | $2,701.58 | $2,772.72 | $3,481.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,183.15 / $6,183.15 / $7,329.51
| Facility | | $6,183.15 | $6,183.15 | $7,329.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,438.30 / $3,438.30 / $3,653.19
| Professional | | $3,438.30 | $3,438.30 | $3,653.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,799.01 / $3,799.01 / $3,799.01
| Facility | | $3,799.01 | $3,799.01 | $3,799.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,229.16 / $3,229.16 / $3,799.01
| Professional | | $3,229.16 | $3,229.16 | $3,799.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,006.22 / $5,006.22 / $15,451.70
| Professional | | $5,006.22 | $5,006.22 | $15,451.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.46 / $3,084.71 / $4,302.18
| Professional | | $2,056.46 | $3,084.71 | $4,302.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,076.26 / $4,483.89 / $5,706.76
| Professional | | $4,076.26 | $4,483.89 | $5,706.76 |