- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,090.41 / $4,090.41 / $4,090.41
| Facility | | $4,090.41 | $4,090.41 | $4,090.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.35 / $3,002.54 / $4,090.41
| Professional | | $1,550.35 | $3,002.54 | $4,090.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,124.18 / $4,124.18 / $4,124.18
| Professional | | $4,124.18 | $4,124.18 | $4,124.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.66 / $2,200.00 / $6,539.06
| Professional | | $354.66 | $2,200.00 | $6,539.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,550.35 / $3,829.32 / $24,693.27
| Facility | | $1,550.35 | $3,829.32 | $24,693.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.92 / $2,263.38 / $3,954.10
| Professional | | $1,508.92 | $2,263.38 | $3,954.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.92 / $2,263.38 / $3,772.30
| Professional | | $1,508.92 | $2,263.38 | $3,772.30 |