- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,391.46 / $5,391.46 / $5,391.46
| Facility | | $5,391.46 | $5,391.46 | $5,391.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,481.64 / $5,391.46 / $5,728.43
| Professional | | $4,481.64 | $5,391.46 | $5,728.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,120.87 / $5,567.69 / $17,692.93
| Facility | | $5,120.87 | $5,567.69 | $17,692.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,391.46 / $6,739.33 / $9,772.03
| Facility | | $5,391.46 | $6,739.33 | $9,772.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,380.56 / $4,380.56 / $6,739.33
| Professional | | $4,380.56 | $4,380.56 | $6,739.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.26 / $10,311.17 / $12,905.82
| Professional | | $7,413.26 | $10,311.17 | $12,905.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,087.20 / $8,087.20 / $8,087.20
| Facility | | $8,087.20 | $8,087.20 | $8,087.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,369.67 / $4,043.60 / $6,739.33
| Professional | | $3,369.67 | $4,043.60 | $6,739.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,726.43 / $32,011.82 / $32,011.82
| Facility | | $11,726.43 | $32,011.82 | $32,011.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33,561.86 / $33,561.86 / $50,544.98
| Professional | | $33,561.86 | $33,561.86 | $50,544.98 |