- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,437.70 / $5,437.70 / $5,437.70
| Facility | | $5,437.70 | $5,437.70 | $5,437.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,094.67 / $3,785.74 / $6,057.18
| Professional | | $2,094.67 | $3,785.74 | $6,057.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,915.31 / $7,915.31 / $7,915.31
| Professional | | $7,915.31 | $7,915.31 | $7,915.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,063.89 / $4,063.89 / $4,063.89
| Facility | | $4,063.89 | $4,063.89 | $4,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.31 / $4,063.89 / $10,710.00
| Professional | | $3,454.31 | $4,063.89 | $10,710.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,094.67 / $5,600.83 / $31,266.85
| Facility | | $2,094.67 | $5,600.83 | $31,266.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,163.08 / $3,865.58 / $9,238.82
| Professional | | $2,163.08 | $3,865.58 | $9,238.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,405.17 / $3,607.77 / $4,999.87
| Professional | | $2,405.17 | $3,607.77 | $4,999.87 |