- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,078.57 / $5,078.57 / $5,078.57
| Facility | | $5,078.57 | $5,078.57 | $5,078.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,050.34 / $5,078.57 / $5,462.26
| Professional | | $5,050.34 | $5,078.57 | $5,462.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,117.70 / $13,981.83 / $18,124.59
| Facility | | $7,117.70 | $13,981.83 | $18,124.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,731.99 / $7,665.21 / $13,140.36
| Professional | | $6,731.99 | $7,665.21 | $13,140.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,503.37 / $7,503.37 / $12,832.38
| Facility | | $7,503.37 | $7,503.37 | $12,832.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $7,503.37 / $50,273.47
| Professional | | $5,477.46 | $7,503.37 | $50,273.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,059.14 / $6,565.29 / $8,611.59
| Professional | | $5,059.14 | $6,565.29 | $8,611.59 |