- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,884.05 / $5,884.05 / $5,884.05
| Facility | | $5,884.05 | $5,884.05 | $5,884.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,884.05 / $6,376.49 / $6,724.63
| Professional | | $5,884.05 | $6,376.49 | $6,724.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,302.44 / $8,302.44 / $8,302.44
| Facility | | $8,302.44 | $8,302.44 | $8,302.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,060.78 / $8,302.44 / $8,302.44
| Professional | | $6,060.78 | $8,302.44 | $8,302.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,419.40 / $8,236.54 / $56,471.55
| Facility | | $3,419.40 | $8,236.54 | $56,471.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,531.07 / $6,999.15 / $13,392.36
| Professional | | $3,531.07 | $6,999.15 | $13,392.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,531.07 / $6,183.59 / $7,978.59
| Professional | | $3,531.07 | $6,183.59 | $7,978.59 |