- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,855.07 / $3,855.07 / $3,855.07
| Facility | | $3,855.07 | $3,855.07 | $3,855.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.07 / $3,877.94 / $34,534.90
| Professional | | $3,855.07 | $3,877.94 | $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 / $14,699.67
| Professional | | $5,928.46 | $5,928.46 | $14,699.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,223.45 / $11,650.73 / $15,145.94
| Professional | | $7,223.45 | $11,650.73 | $15,145.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,974.56 / $15,585.30 / $15,585.30
| Facility | | $13,974.56 | $15,585.30 | $15,585.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,874.81 / $11,171.55 / $16,757.32
| Professional | | $8,874.81 | $11,171.55 | $16,757.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,391.70 / $5,971.46 / $8,545.40
| Professional | | $5,391.70 | $5,971.46 | $8,545.40 |