- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,944.86 / $7,988.43 / $7,988.43
| Facility | | $3,944.86 | $7,988.43 | $7,988.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,835.50 / $5,160.84 / $15,620.00
| Professional | | $4,835.50 | $5,160.84 | $15,620.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.91 / $3,467.91 / $3,467.91
| Professional | | $3,467.91 | $3,467.91 | $3,467.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,575.05 / $7,988.43 / $7,988.43
| Facility | | $7,575.05 | $7,988.43 | $7,988.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,785.51 / $7,500.00 / $16,190.11
| Professional | | $3,785.51 | $7,500.00 | $16,190.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |