- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,330.29 / $4,330.29 / $4,330.29
| Facility | | $4,330.29 | $4,330.29 | $4,330.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,033.64 / $3,033.64 / $4,330.29
| Professional | | $3,033.64 | $3,033.64 | $4,330.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,797.57 / $7,954.72 / $8,092.21
| Professional | | $6,797.57 | $7,954.72 | $8,092.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,865.00 / $5,923.65 / $7,448.55
| Professional | | $5,865.00 | $5,923.65 | $7,448.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $357.11 / $4,330.29 / $26,705.78
| Facility | | $357.11 | $4,330.29 | $26,705.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,580.77 / $2,191.79 / $3,161.53
| Professional | | $1,580.77 | $2,191.79 | $3,161.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.45 / $2,191.79 / $4,880.43
| Professional | | $1,252.45 | $2,191.79 | $4,880.43 |