- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,918.43 / $3,918.43 / $7,103.01
| Facility | | $3,918.43 | $3,918.43 | $7,103.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,918.43 / $3,918.43 / $29,785.70
| Professional | | $3,918.43 | $3,918.43 | $29,785.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,687.89 / $5,687.89 / $5,687.89
| Facility | | $5,687.89 | $5,687.89 | $5,687.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,834.71 / $5,687.89 / $5,858.53
| Professional | | $4,834.71 | $5,687.89 | $5,858.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,668.55 / $7,529.92 / $9,788.89
| Professional | | $4,668.55 | $7,529.92 | $9,788.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,735.84 / $7,220.22 / $10,830.33
| Professional | | $5,735.84 | $7,220.22 | $10,830.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,274.64 / $4,541.22 / $7,124.41
| Professional | | $4,274.64 | $4,541.22 | $7,124.41 |