- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,475.80 / $5,475.80 / $11,636.10
| Facility | | $5,475.80 | $5,475.80 | $11,636.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,435.39 / $4,435.39 / $4,435.39
| Professional | | $4,435.39 | $4,435.39 | $4,435.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,702.85 / $1,702.85 / $3,559.27
| Professional | | $1,702.85 | $1,702.85 | $3,559.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,475.80 / $5,475.80 / $5,530.56
| Professional | | $5,475.80 | $5,475.80 | $5,530.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,475.80 / $5,475.80 / $8,870.79
| Facility | | $5,475.80 | $5,475.80 | $8,870.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,435.39 / $4,435.39 / $5,475.80
| Professional | | $4,435.39 | $4,435.39 | $5,475.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,792.66 / $3,285.48 / $9,582.65
| Professional | | $2,792.66 | $3,285.48 | $9,582.65 |