- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,722.47 / $6,722.47 / $6,722.47
| Facility | | $6,722.47 | $6,722.47 | $6,722.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,595.84 / $4,680.20 / $7,488.32
| Professional | | $2,595.84 | $4,680.20 | $7,488.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,300.68 / $6,300.68 / $6,300.68
| Facility | | $6,300.68 | $6,300.68 | $6,300.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,599.50 / $6,300.68 / $14,114.53
| Professional | | $4,599.50 | $6,300.68 | $14,114.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,595.84 / $7,205.11 / $42,111.30
| Facility | | $2,595.84 | $7,205.11 | $42,111.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,680.62 / $5,118.96 / $11,421.69
| Professional | | $2,680.62 | $5,118.96 | $11,421.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,973.46 / $4,460.18 / $6,196.12
| Professional | | $2,973.46 | $4,460.18 | $6,196.12 |