- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,025.60 / $10,232.93
| Professional | | $4,786.30 | $6,025.60 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Facility | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $11,481.54
| Professional | | $5,888.44 | $5,888.44 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $7,244.36 / $36,307.81
| Facility | | $5,011.87 | $7,244.36 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,888.44 / $15,488.17
| Professional | | $3,467.37 | $5,888.44 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $9,549.93 / $12,302.69
| Facility | | $4,466.84 | $9,549.93 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,370.32 / $7,943.28
| Professional | | $3,467.37 | $5,370.32 | $7,943.28 |