- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,248.62 / $10,248.62 / $10,248.62
| Facility | | $10,248.62 | $10,248.62 | $10,248.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,697.60 / $7,522.93 / $10,248.62
| Professional | | $4,697.60 | $7,522.93 | $10,248.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,860.06 / $7,860.06 / $7,860.06
| Facility | | $7,860.06 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.44 / $7,860.06 / $16,260.94
| Professional | | $814.44 | $7,860.06 | $16,260.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.21 / $6,727.35 / $9,594.45
| Facility | | $1,122.21 | $6,727.35 | $9,594.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,376.05 / $3,780.76 / $6,425.00
| Professional | | $2,376.05 | $3,780.76 | $6,425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,388.98 / $3,780.76 / $5,940.13
| Professional | | $2,388.98 | $3,780.76 | $5,940.13 |