- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,921.81 / $6,921.81 / $6,921.81
| Facility | | $6,921.81 | $6,921.81 | $6,921.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,921.81 / $9,448.82 / $34,534.90
| Professional | | $6,921.81 | $9,448.82 | $34,534.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,121.18 / $8,121.18 / $8,121.18
| Facility | | $8,121.18 | $8,121.18 | $8,121.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,928.46 / $5,928.46 / $15,427.37
| Professional | | $5,928.46 | $5,928.46 | $15,427.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,037.96 / $12,547.46 / $18,821.18
| Professional | | $10,037.96 | $12,547.46 | $18,821.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,855.07 / $3,855.07 / $9,429.49
| Facility | | $3,855.07 | $3,855.07 | $9,429.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,928.46 / $8,121.18 / $14,849.86
| Professional | | $5,928.46 | $8,121.18 | $14,849.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,521.10 / $5,971.46 / $9,137.94
| Professional | | $5,521.10 | $5,971.46 | $9,137.94 |