- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,874.59 / $7,874.59 / $7,874.59
| Facility | | $7,874.59 | $7,874.59 | $7,874.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,197.07 / $7,874.59 / $7,874.59
| Professional | | $5,197.07 | $7,874.59 | $7,874.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,850.52 / $9,850.52 / $57,984.10
| Facility | | $9,850.52 | $9,850.52 | $57,984.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,880.42 / $9,850.52 / $9,850.52
| Professional | | $7,880.42 | $9,850.52 | $9,850.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,100.47 / $7,100.47 / $7,100.47
| Facility | | $7,100.47 | $7,100.47 | $7,100.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,100.47 / $7,100.47 / $7,100.47
| Professional | | $7,100.47 | $7,100.47 | $7,100.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.60 / $7,874.59 / $10,569.00
| Facility | | $5,470.60 | $7,874.59 | $10,569.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,874.45 / $1,913.45 / $1,913.45
| Professional | | $1,874.45 | $1,913.45 | $1,913.45 |