- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,456.74 / $4,456.74 / $4,456.74
| Facility | | $4,456.74 | $4,456.74 | $4,456.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,456.74 / $5,093.41 / $5,419.78
| Professional | | $4,456.74 | $5,093.41 | $5,419.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,415.73 / $9,095.37 / $9,095.37
| Professional | | $7,415.73 | $9,095.37 | $9,095.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,503.37 / $7,503.37 / $7,503.37
| Facility | | $7,503.37 | $7,503.37 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $7,503.37 / $7,503.37
| Professional | | $5,477.46 | $7,503.37 | $7,503.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,034.15 / $6,238.57 / $48,813.24
| Facility | | $3,034.15 | $6,238.57 | $48,813.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,133.24 / $6,210.58 / $10,143.73
| Professional | | $3,133.24 | $6,210.58 | $10,143.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,133.24 / $4,951.02 / $7,079.68
| Professional | | $3,133.24 | $4,951.02 | $7,079.68 |