- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,765.37 / $3,765.37 / $4,518.43
| Facility | | $3,765.37 | $3,765.37 | $4,518.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,781.05 / $2,921.84 / $3,765.37
| Professional | | $2,781.05 | $2,921.84 | $3,765.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,687.26 / $6,687.26 / $7,927.08
| Facility | | $6,687.26 | $6,687.26 | $7,927.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,804.46 / $3,804.46 / $3,974.04
| Professional | | $3,804.46 | $3,804.46 | $3,974.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,366.38 / $4,366.38 / $4,366.38
| Facility | | $4,366.38 | $4,366.38 | $4,366.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.46 / $3,187.46 / $4,497.37
| Professional | | $3,187.46 | $3,187.46 | $4,497.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,414.38 / $5,414.38 / $16,711.48
| Professional | | $5,414.38 | $5,414.38 | $16,711.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.21 / $4,675.34 / $5,414.38
| Professional | | $2,612.21 | $4,675.34 | $5,414.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,008.54 / $5,509.39 / $7,011.96
| Professional | | $5,008.54 | $5,509.39 | $7,011.96 |