- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,677.35 / $8,912.51
| Professional | | $3,890.45 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $8,511.38 / $17,782.79
| Professional | | $6,918.31 | $8,511.38 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $10,964.78
| Facility | | $10,964.78 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $12,302.69
| Professional | | $2,398.83 | $2,691.53 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $5,495.41
| Professional | | $2,290.87 | $2,290.87 | $5,495.41 |