- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,362.06 / $3,362.06 / $3,362.06
| Facility | | $3,362.06 | $3,362.06 | $3,362.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.60 / $3,362.06 / $5,235.53
| Professional | | $2,264.60 | $3,362.06 | $5,235.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,724.11 / $7,555.21 / $13,717.18
| Facility | | $6,724.11 | $7,555.21 | $13,717.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,643.96 / $3,643.96 / $3,935.48
| Professional | | $3,643.96 | $3,643.96 | $3,935.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $4,052.23
| Facility | | $4,052.23 | $4,052.23 | $4,052.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $2,958.13 / $7,135.47
| Professional | | $2,958.13 | $2,958.13 | $7,135.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,797.85 / $3,362.06 / $8,405.14
| Facility | | $1,797.85 | $3,362.06 | $8,405.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,797.85 / $1,797.85 / $1,797.85
| Professional | | $1,797.85 | $1,797.85 | $1,797.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,908.60 / $8,405.14 / $13,313.74
| Professional | | $4,908.60 | $8,405.14 | $13,313.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.82 / $2,784.85 / $4,291.35
| Professional | | $2,574.82 | $2,784.85 | $4,291.35 |