- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,579.84 / $2,579.84 / $2,579.84
| Facility | | $2,579.84 | $2,579.84 | $2,579.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,579.84 / $2,899.21 / $25,818.80
| Professional | | $2,579.84 | $2,899.21 | $25,818.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,541.83 / $6,541.83 / $6,541.83
| Facility | | $6,541.83 | $6,541.83 | $6,541.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $6,541.83 / $6,738.08
| Professional | | $4,775.54 | $6,541.83 | $6,738.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,407.04 / $7,108.14 / $9,240.58
| Professional | | $4,407.04 | $7,108.14 | $9,240.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,525.92 / $9,508.64 / $9,508.64
| Facility | | $8,525.92 | $9,508.64 | $9,508.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,414.55 / $6,815.80 / $10,223.69
| Professional | | $5,414.55 | $6,815.80 | $10,223.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,608.17 / $3,996.14 / $5,732.98
| Professional | | $3,608.17 | $3,996.14 | $5,732.98 |