- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Facility | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,606.93 / $11,220.18
| Professional | | $5,011.87 | $6,606.93 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $13,803.84
| Professional | | $6,309.57 | $6,309.57 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $8,912.51 / $44,668.36
| Facility | | $6,165.95 | $8,912.51 | $44,668.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,244.36 / $19,054.61
| Professional | | $3,715.35 | $7,244.36 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $11,748.98 / $12,882.50
| Facility | | $4,570.88 | $11,748.98 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,165.95 / $8,317.64
| Professional | | $3,715.35 | $6,165.95 | $8,317.64 |