- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,603.43 / $5,603.43 / $5,603.43
| Facility | | $5,603.43 | $5,603.43 | $5,603.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,861.33 / $4,113.16 / $5,603.43
| Professional | | $2,861.33 | $4,113.16 | $5,603.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.00 / $2,187.00 / $4,550.89
| Facility | | $2,187.00 | $2,187.00 | $4,550.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.04 / $2,187.00 / $7,954.69
| Professional | | $418.04 | $2,187.00 | $7,954.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.98 / $4,113.16 / $5,872.68
| Facility | | $630.98 | $4,113.16 | $5,872.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.58 / $2,095.94 / $3,832.40
| Professional | | $1,244.58 | $2,095.94 | $3,832.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.20 / $2,141.55 / $3,807.20
| Professional | | $1,379.20 | $2,141.55 | $3,807.20 |