- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,248.07 / $9,120.11
| Professional | | $4,570.88 | $5,248.07 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Facility | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $10,964.78
| Professional | | $5,248.07 | $5,248.07 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,888.44 / $28,840.32
| Facility | | $3,981.07 | $5,888.44 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,248.07 / $12,302.69
| Professional | | $3,090.30 | $5,248.07 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,413.10 / $10,715.19
| Facility | | $4,365.16 | $7,413.10 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,466.84 / $6,918.31
| Professional | | $3,090.30 | $4,466.84 | $6,918.31 |