- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,947.43 / $4,947.43 / $4,947.43
| Facility | | $4,947.43 | $4,947.43 | $4,947.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,947.43 / $7,710.29 / $14,615.03
| Professional | | $4,947.43 | $7,710.29 | $14,615.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,072.81 / $8,072.81 / $8,072.81
| Facility | | $8,072.81 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.85 / $6,861.89 / $8,072.81
| Professional | | $928.85 | $6,861.89 | $8,072.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,947.43 / $8,170.61 / $13,760.01
| Facility | | $4,947.43 | $8,170.61 | $13,760.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.52 / $1,248.52 / $1,314.23
| Professional | | $1,248.52 | $1,248.52 | $1,314.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.27 / $631.44 / $6,314.47
| Professional | | $394.27 | $631.44 | $6,314.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,435.20 / $3,715.40 / $5,882.71
| Professional | | $3,435.20 | $3,715.40 | $5,882.71 |