- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,754.40 / $5,754.40
| Facility | | $3,162.28 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,162.28 / $3,630.78
| Professional | | $2,691.53 | $3,162.28 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Professional | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,165.95 / $11,748.98
| Facility | | $3,235.94 | $6,165.95 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,620.87 / $18,620.87 / $18,620.87
| Professional | | $18,620.87 | $18,620.87 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,737.80 / $4,786.30
| Professional | | $1,621.81 | $1,737.80 | $4,786.30 |