- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,073.80
| Facility | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,265.80 / $6,606.93
| Professional | | $3,235.94 | $4,265.80 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $7,762.47
| Professional | | $3,630.78 | $3,630.78 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,888.44 / $29,512.09
| Facility | | $4,073.80 | $5,888.44 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,677.35 / $12,589.25
| Professional | | $2,344.23 | $4,677.35 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $7,585.78 / $8,317.64
| Facility | | $3,019.95 | $7,585.78 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,890.45 / $5,370.32
| Professional | | $2,344.23 | $3,890.45 | $5,370.32 |