- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,135.75 / $3,135.75 / $3,135.75
| Facility | | $3,135.75 | $3,135.75 | $3,135.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.23 / $2,301.77 / $3,135.75
| Professional | | $1,601.23 | $2,301.77 | $3,135.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,793.86 / $5,793.86 / $5,793.86
| Professional | | $5,793.86 | $5,793.86 | $5,793.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.17 / $2,225.09 / $4,710.93
| Professional | | $246.17 | $2,225.09 | $4,710.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $339.87 / $2,301.77 / $16,659.23
| Facility | | $339.87 | $2,301.77 | $16,659.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.71 / $1,157.28 / $2,071.92
| Professional | | $737.71 | $1,157.28 | $2,071.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.52 / $1,157.28 / $2,071.92
| Professional | | $771.52 | $1,157.28 | $2,071.92 |