- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,370.32 / $11,220.18
| Professional | | $3,801.89 | $5,370.32 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $9,772.37
| Professional | | $6,456.54 | $6,456.54 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,025.60 / $45,708.82
| Facility | | $3,981.07 | $6,025.60 | $45,708.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,606.93 / $56,234.13
| Professional | | $3,715.35 | $6,606.93 | $56,234.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,413.10 / $8,709.64
| Facility | | $4,677.35 | $7,413.10 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,495.41 / $13,182.57
| Professional | | $3,715.35 | $5,495.41 | $13,182.57 |