- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,785.60 / $4,785.60 / $4,785.60
| Facility | | $4,785.60 | $4,785.60 | $4,785.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,785.60 / $7,458.11 / $14,137.01
| Professional | | $4,785.60 | $7,458.11 | $14,137.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $4,978.93 / $4,978.93
| Facility | | $4,978.93 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.47 / $4,978.93 / $5,128.30
| Professional | | $898.47 | $4,978.93 | $5,128.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,785.60 / $7,903.37 / $13,309.89
| Facility | | $4,785.60 | $7,903.37 | $13,309.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.68 / $1,207.68 / $1,271.24
| Professional | | $1,207.68 | $1,207.68 | $1,271.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.38 / $625.44 / $6,107.93
| Professional | | $381.38 | $625.44 | $6,107.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,322.84 / $3,593.88 / $5,690.31
| Professional | | $3,322.84 | $3,593.88 | $5,690.31 |