- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.79 / $3,745.79 / $3,745.79
| Facility | | $3,745.79 | $3,745.79 | $3,745.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,745.79 / $3,745.79 / $6,780.61
| Professional | | $3,745.79 | $3,745.79 | $6,780.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,299.43 / $8,040.40 / $14,098.13
| Facility | | $5,299.43 | $8,040.40 | $14,098.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,794.03 / $3,794.03 / $6,784.35
| Professional | | $3,794.03 | $3,794.03 | $6,784.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,378.00 / $7,284.19 / $8,934.85
| Facility | | $3,378.00 | $7,284.19 | $8,934.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.02 / $9,554.92 / $21,596.04
| Professional | | $5,370.02 | $9,554.92 | $21,596.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,471.77 / $9,554.92 / $15,793.11
| Professional | | $5,471.77 | $9,554.92 | $15,793.11 |