- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,309.57 / $10,471.29
| Professional | | $4,365.16 | $6,309.57 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $11,220.18
| Facility | | $10,715.19 | $10,715.19 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $8,317.64
| Professional | | $6,456.54 | $6,456.54 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $8,128.31 / $9,120.11
| Facility | | $6,025.60 | $8,128.31 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,888.44 / $8,128.31
| Professional | | $5,248.07 | $5,888.44 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $10,715.19 / $18,620.87
| Professional | | $6,025.60 | $10,715.19 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,715.19 / $14,454.40
| Professional | | $10,471.29 | $10,715.19 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,248.07 / $7,943.28
| Facility | | $3,981.07 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,585.78 / $10,471.29
| Professional | | $4,897.79 | $7,585.78 | $10,471.29 |