- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,034.15 / $3,034.15 / $3,034.15
| Facility | | $3,034.15 | $3,034.15 | $3,034.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,034.15 / $3,134.05 / $27,910.20
| Professional | | $3,034.15 | $3,134.05 | $27,910.20 |
- 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 / $7,998.97
| Professional | | $5,477.46 | $7,503.37 | $7,998.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,971.39 / $8,018.38 / $10,423.89
| Professional | | $4,971.39 | $8,018.38 | $10,423.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,617.70 / $10,726.27 / $10,726.27
| Facility | | $9,617.70 | $10,726.27 | $10,726.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,107.91 / $7,688.59 / $11,532.89
| Professional | | $6,107.91 | $7,688.59 | $11,532.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,243.56 / $4,699.85 / $6,725.70
| Professional | | $4,243.56 | $4,699.85 | $6,725.70 |