- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,237.14 / $4,237.14 / $4,237.14
| Facility | | $4,237.14 | $4,237.14 | $4,237.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,480.60 / $4,237.14 / $6,379.39
| Professional | | $3,480.60 | $4,237.14 | $6,379.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,474.28 / $9,521.70 / $17,287.53
| Facility | | $8,474.28 | $9,521.70 | $17,287.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,912.29 / $6,450.00 / $6,450.00
| Professional | | $5,912.29 | $6,450.00 | $6,450.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,751.45 / $4,751.45 / $4,751.45
| Facility | | $4,751.45 | $4,751.45 | $4,751.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,038.73 / $4,038.73 / $8,854.84
| Professional | | $4,038.73 | $4,038.73 | $8,854.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.52 / $4,237.14 / $11,824.68
| Facility | | $2,571.52 | $4,237.14 | $11,824.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,571.52 / $2,571.52 / $2,571.52
| Professional | | $2,571.52 | $2,571.52 | $2,571.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,186.22 / $10,592.85 / $16,948.56
| Professional | | $6,186.22 | $10,592.85 | $16,948.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,507.47 / $3,793.57 / $5,845.78
| Professional | | $3,507.47 | $3,793.57 | $5,845.78 |