- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,780.00 / $8,747.40 / $9,703.40
| Facility | | $4,780.00 | $8,747.40 | $9,703.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,776.20 / $5,258.00 / $9,703.40
| Professional | | $3,776.20 | $5,258.00 | $9,703.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,895.33 / $5,895.33 / $5,895.33
| Facility | | $5,895.33 | $5,895.33 | $5,895.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,895.33 / $5,895.33 / $5,895.33
| Professional | | $5,895.33 | $5,895.33 | $5,895.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,107.00 / $3,262.35 / $4,008.03
| Facility | | $3,107.00 | $3,262.35 | $4,008.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.07 / $4,479.67 / $6,865.61
| Professional | | $2,070.07 | $4,479.67 | $6,865.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.60 / $2,868.00 / $8,126.00
| Professional | | $2,007.60 | $2,868.00 | $8,126.00 |