- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,748.04 / $3,821.53 / $3,821.53
| Facility | | $3,748.04 | $3,821.53 | $3,821.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,745.38 / $3,821.53 / $6,565.31
| Professional | | $3,745.38 | $3,821.53 | $6,565.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,255.57 / $7,938.81 / $7,938.81
| Professional | | $5,255.57 | $7,938.81 | $7,938.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,809.41 / $4,938.58 / $4,938.58
| Facility | | $3,809.41 | $4,938.58 | $4,938.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,605.16 / $3,605.16 / $4,938.58
| Professional | | $3,605.16 | $3,605.16 | $4,938.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,908.22 / $37,094.85 / $37,094.85
| Facility | | $11,908.22 | $37,094.85 | $37,094.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47,035.20 / $47,035.20 / $64,549.05
| Professional | | $47,035.20 | $47,035.20 | $64,549.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,933.77 / $4,308.82 / $5,638.77
| Professional | | $2,933.77 | $4,308.82 | $5,638.77 |