- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,091.22 / $5,091.22 / $5,091.22
| Facility | | $5,091.22 | $5,091.22 | $5,091.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,599.78 / $3,737.18 / $5,091.22
| Professional | | $2,599.78 | $3,737.18 | $5,091.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,221.09 / $8,221.09 / $8,221.09
| Professional | | $8,221.09 | $8,221.09 | $8,221.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $4,219.47
| Facility | | $2,673.00 | $2,673.00 | $4,219.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.53 / $2,673.00 / $7,195.31
| Professional | | $378.53 | $2,673.00 | $7,195.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.04 / $3,737.18 / $5,376.08
| Facility | | $555.04 | $3,737.18 | $5,376.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.83 / $1,918.80 / $3,546.56
| Professional | | $1,188.83 | $1,918.80 | $3,546.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.17 / $1,918.80 / $3,522.67
| Professional | | $1,253.17 | $1,918.80 | $3,522.67 |