- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,782.39 / $4,782.39 / $4,782.39
| Facility | | $4,782.39 | $4,782.39 | $4,782.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,968.56 / $3,968.56 / $4,782.39
| Professional | | $3,968.56 | $3,968.56 | $4,782.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,492.79 / $7,676.77 / $7,775.31
| Professional | | $6,492.79 | $7,676.77 | $7,775.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,708.75 / $6,775.84 / $8,520.11
| Professional | | $6,708.75 | $6,775.84 | $8,520.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.05 / $4,782.39 / $29,293.49
| Facility | | $524.05 | $4,782.39 | $29,293.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,422.55 / $3,453.76 / $5,750.08
| Professional | | $2,422.55 | $3,453.76 | $5,750.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.06 / $3,351.36 / $7,066.42
| Professional | | $1,915.06 | $3,351.36 | $7,066.42 |