- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,609.85 / $3,609.85 / $3,609.85
| Facility | | $3,609.85 | $3,609.85 | $3,609.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,609.85 / $3,609.85 / $4,256.39
| Professional | | $3,609.85 | $3,609.85 | $4,256.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,975.13 / $5,472.64 / $5,527.92
| Professional | | $4,975.13 | $5,472.64 | $5,527.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,798.08 / $6,226.65 / $6,226.65
| Facility | | $3,798.08 | $6,226.65 | $6,226.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,798.08 / $6,226.65 / $9,601.62
| Professional | | $3,798.08 | $6,226.65 | $9,601.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.54 / $6,136.75 / $24,802.46
| Facility | | $2,941.54 | $6,136.75 | $24,802.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.14 / $3,127.21 / $4,706.68
| Professional | | $2,155.14 | $3,127.21 | $4,706.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,208.44 / $6,226.65 / $7,845.38
| Facility | | $6,208.44 | $6,226.65 | $7,845.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,177.35 / $7,273.58 / $12,827.93
| Professional | | $5,177.35 | $7,273.58 | $12,827.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.82 / $2,824.01 / $3,615.87
| Professional | | $2,119.82 | $2,824.01 | $3,615.87 |