- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,163.91 / $3,163.91 / $3,163.91
| Facility | | $3,163.91 | $3,163.91 | $3,163.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,623.70 / $2,623.70 / $3,163.91
| Professional | | $2,623.70 | $2,623.70 | $3,163.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,933.80 / $4,603.43 / $4,683.01
| Professional | | $3,933.80 | $4,603.43 | $4,683.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,993.75 / $4,033.69 / $5,072.06
| Professional | | $3,993.75 | $4,033.69 | $5,072.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.61 / $3,163.91 / $4,879.47
| Facility | | $273.61 | $3,163.91 | $4,879.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.37 / $2,041.20 / $3,061.80
| Professional | | $982.37 | $2,041.20 | $3,061.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.97 / $204.97 / $2,383.14
| Facility | | $204.97 | $204.97 | $2,383.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.12 / $1,385.32 / $3,061.80
| Professional | | $827.12 | $1,385.32 | $3,061.80 |