- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.74 / $2,970.74 / $2,970.74
| Facility | | $2,970.74 | $2,970.74 | $2,970.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,970.74 / $3,251.77 / $28,958.60
| Professional | | $2,970.74 | $3,251.77 | $28,958.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,652.12 / $6,652.12 / $6,652.12
| Facility | | $6,652.12 | $6,652.12 | $6,652.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,856.05 / $6,652.12 / $6,851.68
| Professional | | $4,856.05 | $6,652.12 | $6,851.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,696.05 / $7,574.29 / $9,846.57
| Professional | | $4,696.05 | $7,574.29 | $9,846.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,085.04 / $10,132.20 / $10,132.20
| Facility | | $9,085.04 | $10,132.20 | $10,132.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,769.63 / $7,262.77 / $10,894.15
| Professional | | $5,769.63 | $7,262.77 | $10,894.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,154.88 / $4,601.64 / $6,601.65
| Professional | | $4,154.88 | $4,601.64 | $6,601.65 |