- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,360.54 / $5,360.54 / $5,360.54
| Facility | | $5,360.54 | $5,360.54 | $5,360.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,736.54 / $4,147.04 / $5,360.54
| Professional | | $2,736.54 | $4,147.04 | $5,360.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,192.08 / $3,192.08 / $3,192.08
| Professional | | $3,192.08 | $3,192.08 | $3,192.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.00 / $6,495.00 / $8,118.75
| Professional | | $462.00 | $6,495.00 | $8,118.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,736.54 / $4,147.04 / $21,533.82
| Facility | | $2,736.54 | $4,147.04 | $21,533.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.26 / $2,729.15 / $5,347.78
| Professional | | $1,756.26 | $2,729.15 | $5,347.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.26 / $2,729.15 / $4,591.35
| Professional | | $1,756.26 | $2,729.15 | $4,591.35 |