- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,848.03 / $4,848.03 / $4,848.03
| Facility | | $4,848.03 | $4,848.03 | $4,848.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,291.93 / $4,291.93 / $4,848.03
| Professional | | $4,291.93 | $4,291.93 | $4,848.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,610.28 / $8,905.77 / $9,059.69
| Professional | | $7,610.28 | $8,905.77 | $9,059.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,298.75 / $8,381.74 / $10,539.41
| Professional | | $8,298.75 | $8,381.74 | $10,539.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $626.21 / $4,848.03 / $33,203.46
| Facility | | $626.21 | $4,848.03 | $33,203.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,964.94 / $3,486.60 / $3,929.87
| Professional | | $1,964.94 | $3,486.60 | $3,929.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.64 / $2,440.62 / $3,929.87
| Professional | | $1,394.64 | $2,440.62 | $3,929.87 |