- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,016.78 / $5,016.78 / $5,016.78
| Facility | | $5,016.78 | $5,016.78 | $5,016.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,561.76 / $3,682.53 / $5,016.78
| Professional | | $2,561.76 | $3,682.53 | $5,016.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,736.50 / $5,736.50 / $5,736.50
| Professional | | $5,736.50 | $5,736.50 | $5,736.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,621.85
| Facility | | $3,621.85 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.96 / $3,621.85 / $7,134.38
| Professional | | $386.96 | $3,621.85 | $7,134.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,936.64 / $3,682.53 / $5,237.12
| Facility | | $2,936.64 | $3,682.53 | $5,237.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.80 / $1,869.16 / $3,641.20
| Professional | | $1,234.80 | $1,869.16 | $3,641.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.80 / $1,869.16 / $3,322.06
| Professional | | $1,234.80 | $1,869.16 | $3,322.06 |