- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,710.03 / $3,782.77 / $3,782.77
| Facility | | $3,710.03 | $3,782.77 | $3,782.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,688.65 / $3,782.77 / $6,498.73
| Professional | | $3,688.65 | $3,782.77 | $6,498.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,202.28 / $7,858.30 / $7,858.30
| Professional | | $5,202.28 | $7,858.30 | $7,858.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,530.84 / $6,042.00 / $6,042.00
| Facility | | $4,530.84 | $6,042.00 | $6,042.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,410.66 / $4,410.66 / $6,042.00
| Professional | | $4,410.66 | $4,410.66 | $6,042.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,787.44 / $40,507.83 / $40,507.83
| Facility | | $11,787.44 | $40,507.83 | $40,507.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43,722.41 / $43,722.41 / $63,571.35
| Professional | | $43,722.41 | $43,722.41 | $63,571.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,904.02 / $4,356.02 / $5,922.73
| Professional | | $2,904.02 | $4,356.02 | $5,922.73 |