- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,944.71 / $4,944.71 / $4,944.71
| Facility | | $4,944.71 | $4,944.71 | $4,944.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,075.47 / $4,075.47 / $4,944.71
| Professional | | $4,075.47 | $4,075.47 | $4,944.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.17 / $9,083.52 / $9,240.52
| Professional | | $7,762.17 | $9,083.52 | $9,240.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,878.75 / $7,957.54 / $10,006.01
| Professional | | $7,878.75 | $7,957.54 | $10,006.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,307.68 / $4,944.71 / $30,495.32
| Facility | | $3,307.68 | $4,944.71 | $30,495.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,301.37 / $3,337.21 / $4,799.68
| Professional | | $2,301.37 | $3,337.21 | $4,799.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.98 / $3,337.21 / $6,856.70
| Professional | | $1,906.98 | $3,337.21 | $6,856.70 |