- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,612.61 / $3,612.61 / $3,612.61
| Facility | | $3,612.61 | $3,612.61 | $3,612.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,451.53 / $3,138.41 / $3,612.61
| Professional | | $2,451.53 | $3,138.41 | $3,612.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,571.40 / $6,587.36 / $6,751.23
| Professional | | $5,571.40 | $6,587.36 | $6,751.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,067.50 / $6,128.18 / $7,705.73
| Professional | | $6,067.50 | $6,128.18 | $7,705.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.20 / $3,612.61 / $5,250.00
| Facility | | $315.20 | $3,612.61 | $5,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.82 / $306.17 / $3,596.30
| Professional | | $197.82 | $306.17 | $3,596.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $377.93 / $3,596.30
| Professional | | $151.16 | $377.93 | $3,596.30 |