- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,606.93 / $12,882.50
| Professional | | $4,570.88 | $6,606.93 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,748.98
| Facility | | $11,220.18 | $11,220.18 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $8,912.51
| Professional | | $6,760.83 | $6,760.83 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $8,709.64 / $8,709.64
| Facility | | $6,456.54 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,309.57 / $8,709.64
| Professional | | $5,495.41 | $6,309.57 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $11,220.18 / $19,952.62
| Professional | | $6,309.57 | $11,220.18 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $14,454.40
| Professional | | $11,220.18 | $11,220.18 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,495.41 / $8,317.64
| Facility | | $4,168.69 | $5,495.41 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,943.28 / $11,220.18
| Professional | | $5,128.61 | $7,943.28 | $11,220.18 |