- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,918.31
| Facility | | $5,128.61 | $5,128.61 | $6,918.31 |
- 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
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,248.07 / $7,413.10
| Professional | | $4,786.30 | $5,248.07 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $16,595.87 / $16,595.87
| Facility | | $64.57 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,754.40 / $7,079.46
| Professional | | $5,623.41 | $5,754.40 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $398.11 / $812.83
| Professional | | $338.84 | $398.11 | $812.83 |