- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Facility | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,760.83 / $11,748.98
| Professional | | $5,623.41 | $6,760.83 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Facility | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $13,489.63
| Professional | | $6,606.93 | $6,606.93 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,317.64 / $41,686.94
| Facility | | $5,754.40 | $8,317.64 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,918.31 / $17,378.01
| Professional | | $4,073.80 | $6,918.31 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $10,715.19 / $14,125.38
| Facility | | $5,128.61 | $10,715.19 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,165.95 / $9,120.11
| Professional | | $4,073.80 | $6,165.95 | $9,120.11 |