- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,060.26 / $5,060.26 / $5,060.26
| Facility | | $5,060.26 | $5,060.26 | $5,060.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,987.30 / $5,060.26 / $7,558.02
| Professional | | $3,987.30 | $5,060.26 | $7,558.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $4,377.82
| Facility | | $2,900.00 | $2,900.00 | $4,377.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.34 / $2,900.00 / $2,987.00
| Professional | | $480.34 | $2,900.00 | $2,987.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,860.57 / $3,941.86 / $5,628.03
| Facility | | $1,860.57 | $3,941.86 | $5,628.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.66 / $645.66 / $679.65
| Professional | | $645.66 | $645.66 | $679.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.27 / $509.74 / $4,898.25
| Professional | | $297.27 | $509.74 | $4,898.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,664.65 / $2,860.46 / $4,864.24
| Professional | | $2,664.65 | $2,860.46 | $4,864.24 |