- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,027.30 / $7,027.30 / $7,027.30
| Facility | | $7,027.30 | $7,027.30 | $7,027.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,835.12 / $5,835.12 / $7,027.30
| Professional | | $5,835.12 | $5,835.12 | $7,027.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,609.61 / $12,415.68 / $12,630.27
| Professional | | $10,609.61 | $12,415.68 | $12,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,770.00 / $10,877.70 / $13,677.90
| Professional | | $10,770.00 | $10,877.70 | $13,677.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.31 / $7,027.30 / $42,593.27
| Facility | | $426.31 | $7,027.30 | $42,593.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,563.46 / $4,020.71 / $5,810.49
| Professional | | $2,563.46 | $4,020.71 | $5,810.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,896.29 / $3,873.66 / $5,810.49
| Professional | | $1,896.29 | $3,873.66 | $5,810.49 |