- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,630.27 / $5,128.61
| Professional | | $2,187.76 | $2,630.27 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $4,677.35
| Facility | | $3,890.45 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,786.30 / $10,000.00
| Professional | | $3,890.45 | $4,786.30 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $6,165.95
| Facility | | $6,165.95 | $6,165.95 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $6,760.83
| Professional | | $5,011.87 | $5,011.87 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $3,090.30
| Professional | | $1,318.26 | $1,318.26 | $3,090.30 |