- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,795.43 / $3,869.85 / $3,869.85
| Facility | | $3,795.43 | $3,869.85 | $3,869.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,104.81 / $3,869.85 / $6,648.32
| Professional | | $3,104.81 | $3,869.85 | $6,648.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,322.03 / $8,039.18 / $8,039.18
| Professional | | $5,322.03 | $8,039.18 | $8,039.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,761.88 / $4,697.47 / $4,697.47
| Facility | | $3,761.88 | $4,697.47 | $4,697.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $3,429.16 / $4,697.47
| Professional | | $3,429.16 | $3,429.16 | $4,697.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,058.77 / $35,737.98 / $35,737.98
| Facility | | $12,058.77 | $35,737.98 | $35,737.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46,448.37 / $46,448.37 / $52,782.23
| Professional | | $46,448.37 | $46,448.37 | $52,782.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,925.83 / $4,456.30 / $5,410.34
| Professional | | $2,925.83 | $4,456.30 | $5,410.34 |