- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,211.18 / $8,211.18 / $8,211.18
| Facility | | $8,211.18 | $8,211.18 | $8,211.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.88 / $6,027.36 / $8,211.18
| Professional | | $3,454.88 | $6,027.36 | $8,211.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,793.86 / $5,793.86 / $5,793.86
| Professional | | $5,793.86 | $5,793.86 | $5,793.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,087.00 / $3,087.00 / $3,087.00
| Facility | | $3,087.00 | $3,087.00 | $3,087.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.63 / $3,087.00 / $13,298.44
| Professional | | $648.63 | $3,087.00 | $13,298.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,454.88 / $6,027.36 / $7,687.06
| Facility | | $3,454.88 | $6,027.36 | $7,687.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.68 / $2,880.45 / $4,324.20
| Professional | | $1,729.68 | $2,880.45 | $4,324.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.01 / $2,594.52 / $4,114.93
| Professional | | $1,757.01 | $2,594.52 | $4,114.93 |