- 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
- $1,348.96 / $2,238.72 / $3,090.30
| Professional | | $1,348.96 | $2,238.72 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Professional | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $3,630.78 / $3,715.35
| Professional | | $190.55 | $3,630.78 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $2,344.23 / $9,549.93
| Facility | | $501.19 | $2,344.23 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $467.74 / $2,884.03
| Professional | | $102.33 | $467.74 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $354.81 / $3,090.30
| Facility | | $213.80 | $354.81 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $616.60 / $3,090.30
| Professional | | $154.88 | $616.60 | $3,090.30 |