- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Facility | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,890.45 / $5,754.40
| Professional | | $2,754.23 | $3,890.45 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $8,317.64 / $8,709.64
| Professional | | $7,079.46 | $8,317.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $9,332.54
| Professional | | $7,413.10 | $7,413.10 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,570.88 / $33,113.11
| Facility | | $3,548.13 | $4,570.88 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,090.30 / $5,623.41
| Professional | | $2,511.89 | $3,090.30 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $3,090.30 / $4,168.69
| Facility | | $407.38 | $3,090.30 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $7,244.36
| Professional | | $2,454.71 | $3,715.35 | $7,244.36 |