- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,403.52 / $3,470.25 / $3,470.25
| Facility | | $3,403.52 | $3,470.25 | $3,470.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,403.52 / $3,485.82 / $6,090.10
| Professional | | $3,403.52 | $3,485.82 | $6,090.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,772.47 / $7,209.08 / $7,209.08
| Professional | | $4,772.47 | $7,209.08 | $7,209.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,281.70 / $6,541.83 / $6,541.83
| Facility | | $4,281.70 | $6,541.83 | $6,541.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $4,775.54 / $6,541.83
| Professional | | $4,775.54 | $4,775.54 | $6,541.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,813.62 / $42,519.53 / $42,519.53
| Facility | | $10,813.62 | $42,519.53 | $42,519.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48,489.51 / $48,489.51 / $60,075.68
| Professional | | $48,489.51 | $48,489.51 | $60,075.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,664.10 / $3,996.14 / $6,020.97
| Professional | | $2,664.10 | $3,996.14 | $6,020.97 |