- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,495.41 / $5,495.41
| Facility | | $4,570.88 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,884.03 / $3,090.30
| Professional | | $2,570.40 | $2,884.03 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,888.44 / $10,964.78
| Facility | | $3,090.30 | $5,888.44 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,782.79 / $17,782.79 / $17,782.79
| Professional | | $17,782.79 | $17,782.79 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,659.59 / $4,570.88
| Professional | | $1,548.82 | $1,659.59 | $4,570.88 |