- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,890.45
| Facility | | $3,311.31 | $3,311.31 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,511.89 / $3,890.45
| Professional | | $1,819.70 | $2,511.89 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,011.87 / $5,495.41
| Professional | | $3,801.89 | $5,011.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $6,760.83
| Professional | | $5,370.32 | $5,370.32 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $22,387.21
| Facility | | $1,819.70 | $4,073.80 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,290.87 / $4,570.88
| Professional | | $1,819.70 | $2,290.87 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $6,760.83 / $6,760.83
| Facility | | $2,754.23 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,090.30 / $5,011.87
| Professional | | $1,621.81 | $3,090.30 | $5,011.87 |