- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Facility | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,884.03 / $4,265.80
| Professional | | $1,905.46 | $2,884.03 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,128.61 / $5,128.61
| Professional | | $3,981.07 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Professional | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38,018.94 / $38,018.94 / $38,018.94
| Professional | | $38,018.94 | $38,018.94 | $38,018.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $338.84 / $3,019.95
| Facility | | $302.00 | $338.84 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $269.15 / $2,454.71
| Professional | | $204.17 | $269.15 | $2,454.71 |