- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,309.57 / $8,128.31
| Professional | | $5,370.32 | $6,309.57 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Professional | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $3,715.35 / $12,882.50
| Professional | | $812.83 | $3,715.35 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $199.53 / $199.53
| Professional | | $100.00 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,174.90 / $7,585.78
| Facility | | $316.23 | $1,174.90 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,715.35 / $6,165.95
| Professional | | $2,570.40 | $3,715.35 | $6,165.95 |