- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,233.47 / $6,233.47 / $6,233.47
| Facility | | $6,233.47 | $6,233.47 | $6,233.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,975.33 / $4,555.07 / $6,943.61
| Professional | | $3,975.33 | $4,555.07 | $6,943.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,551.49 / $7,551.49 / $7,551.49
| Facility | | $7,551.49 | $7,551.49 | $7,551.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,418.77 / $7,551.49 / $12,178.13
| Professional | | $6,418.77 | $7,551.49 | $12,178.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,555.07 / $7,523.42 / $45,439.44
| Facility | | $4,555.07 | $7,523.42 | $45,439.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,705.97 / $8,732.10 / $26,373.17
| Professional | | $3,705.97 | $8,732.10 | $26,373.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,554.02 / $5,558.95 / $13,938.08
| Professional | | $3,554.02 | $5,558.95 | $13,938.08 |