- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,383.63 / $5,383.63 / $5,383.63
| Facility | | $5,383.63 | $5,383.63 | $5,383.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,383.63 / $6,152.72 / $6,152.72
| Professional | | $5,383.63 | $6,152.72 | $6,152.72 |
- 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 / $14,554.13
| Professional | | $5,928.46 | $5,928.46 | $14,554.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,855.07 / $7,536.05 / $62,341.20
| Facility | | $3,855.07 | $7,536.05 | $62,341.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,980.97 / $7,890.92 / $12,253.38
| Professional | | $3,980.97 | $7,890.92 | $12,253.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,980.97 / $5,971.46 / $8,995.16
| Professional | | $3,980.97 | $5,971.46 | $8,995.16 |