- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,313.68 / $4,313.68 / $4,313.68
| Facility | | $4,313.68 | $4,313.68 | $4,313.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,313.68 / $5,951.21 / $11,939.02
| Professional | | $4,313.68 | $5,951.21 | $11,939.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,608.68 / $7,608.68 / $7,608.68
| Facility | | $7,608.68 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.92 / $6,467.38 / $7,608.68
| Professional | | $816.92 | $6,467.38 | $7,608.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,063.65 / $6,128.86 / $11,939.02
| Facility | | $1,063.65 | $6,128.86 | $11,939.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.44 / $550.58 / $4,129.33
| Professional | | $187.44 | $550.58 | $4,129.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,995.28 / $3,357.32 / $5,623.80
| Professional | | $2,995.28 | $3,357.32 | $5,623.80 |