- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,786.21 / $3,786.21 / $3,786.21
| Facility | | $3,786.21 | $3,786.21 | $3,786.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,145.15 / $3,145.15 / $3,786.21
| Professional | | $3,145.15 | $3,145.15 | $3,786.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,032.26 / $7,059.13 / $7,181.14
| Professional | | $6,032.26 | $7,059.13 | $7,181.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,123.75 / $6,184.99 / $7,777.16
| Professional | | $6,123.75 | $6,184.99 | $7,777.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,986.09 / $3,786.21 / $27,719.97
| Facility | | $2,986.09 | $3,786.21 | $27,719.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,106.80 / $3,103.24 / $4,654.85
| Professional | | $2,106.80 | $3,103.24 | $4,654.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.84 / $4,213.60 / $4,654.85
| Professional | | $1,730.84 | $4,213.60 | $4,654.85 |