- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,380.64 / $4,380.64 / $4,380.64
| Facility | | $4,380.64 | $4,380.64 | $4,380.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,641.41 / $4,380.64 / $4,654.43
| Professional | | $3,641.41 | $4,380.64 | $4,654.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,160.79 / $4,523.83 / $14,375.51
| Facility | | $4,160.79 | $4,523.83 | $14,375.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,380.64 / $5,475.80 / $7,939.91
| Facility | | $4,380.64 | $5,475.80 | $7,939.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,559.27 / $3,559.27 / $5,475.80
| Professional | | $3,559.27 | $3,559.27 | $5,475.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,023.38 / $8,377.96 / $10,486.16
| Professional | | $6,023.38 | $8,377.96 | $10,486.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $3,285.48 / $5,640.07
| Professional | | $2,299.84 | $3,285.48 | $5,640.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,527.89 / $26,010.05 / $26,010.05
| Facility | | $9,527.89 | $26,010.05 | $26,010.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,269.48 / $27,269.48 / $41,068.50
| Professional | | $27,269.48 | $27,269.48 | $41,068.50 |