- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,884.03 / $3,467.37
| Professional | | $1,862.09 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $10,964.78 / $20,892.96
| Facility | | $4,265.80 | $10,964.78 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,630.78 / $3,630.78
| Professional | | $2,754.23 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,606.93 / $7,762.47
| Facility | | $2,818.38 | $6,606.93 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $2,951.21 / $4,466.84
| Professional | | $707.95 | $2,951.21 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $588.84 / $3,715.35
| Facility | | $295.12 | $588.84 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,884.03 / $4,677.35
| Professional | | $1,819.70 | $2,884.03 | $4,677.35 |