- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,878.55 / $6,878.55 / $6,878.55
| Facility | | $6,878.55 | $6,878.55 | $6,878.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,920.30 / $4,788.85 / $7,662.18
| Professional | | $2,920.30 | $4,788.85 | $7,662.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,012.68 / $10,012.68 / $10,012.68
| Professional | | $10,012.68 | $10,012.68 | $10,012.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,553.03 / $6,553.03 / $6,553.03
| Facility | | $6,553.03 | $6,553.03 | $6,553.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.71 / $6,553.03 / $14,679.84
| Professional | | $4,783.71 | $6,553.03 | $14,679.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,920.30 / $7,372.39 / $46,975.22
| Facility | | $2,920.30 | $7,372.39 | $46,975.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,015.68 / $5,237.81 / $11,686.85
| Professional | | $3,015.68 | $5,237.81 | $11,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,042.50 / $4,563.74 / $6,970.60
| Professional | | $3,042.50 | $4,563.74 | $6,970.60 |