- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,120.90 / $2,120.90 / $2,120.90
| Facility | | $2,120.90 | $2,120.90 | $2,120.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.90 / $2,120.90 / $17,765.40
| Professional | | $2,120.90 | $2,120.90 | $17,765.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $3,728.42
| Facility | | $3,728.42 | $3,728.42 | $3,728.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $3,728.42 / $3,840.27
| Professional | | $2,721.75 | $3,728.42 | $3,840.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,785.47 / $4,492.70 / $5,840.51
| Professional | | $2,785.47 | $4,492.70 | $5,840.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,388.80 / $6,009.93 / $6,009.93
| Facility | | $5,388.80 | $6,009.93 | $6,009.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,422.27 / $4,307.92 / $6,461.88
| Professional | | $3,422.27 | $4,307.92 | $6,461.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,313.71 / $2,562.50 / $3,856.19
| Professional | | $2,313.71 | $2,562.50 | $3,856.19 |