- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,291.84 / $5,291.84 / $5,291.84
| Facility | | $5,291.84 | $5,291.84 | $5,291.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.64 / $3,684.19 / $5,894.71
| Professional | | $2,266.64 | $3,684.19 | $5,894.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,590.86 / $8,590.86 / $8,590.86
| Professional | | $8,590.86 | $8,590.86 | $8,590.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,697.47 / $4,697.47 / $4,697.47
| Facility | | $4,697.47 | $4,697.47 | $4,697.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $3,429.16 / $10,522.97
| Professional | | $3,429.16 | $3,429.16 | $10,522.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,266.64 / $5,671.76 / $35,737.98
| Facility | | $2,266.64 | $5,671.76 | $35,737.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.66 / $4,029.58 / $8,990.99
| Professional | | $2,340.66 | $4,029.58 | $8,990.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.66 / $3,511.00 / $5,410.34
| Professional | | $2,340.66 | $3,511.00 | $5,410.34 |