- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,936.72 / $4,013.91 / $4,013.91
| Facility | | $3,936.72 | $4,013.91 | $4,013.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,936.72 / $4,399.85 / $6,895.81
| Professional | | $3,936.72 | $4,399.85 | $6,895.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,520.14 / $8,338.45 / $8,338.45
| Professional | | $5,520.14 | $8,338.45 | $8,338.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,889.84 / $6,553.03 / $6,553.03
| Facility | | $4,889.84 | $6,553.03 | $6,553.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.71 / $4,783.71 / $6,553.03
| Professional | | $4,783.71 | $4,783.71 | $6,553.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,507.70 / $46,975.22 / $46,975.22
| Facility | | $12,507.70 | $46,975.22 | $46,975.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59,843.37 / $59,843.37 / $90,671.78
| Professional | | $59,843.37 | $59,843.37 | $90,671.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.46 / $4,622.18 / $6,815.55
| Professional | | $3,081.46 | $4,622.18 | $6,815.55 |