- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,984.81 / $3,984.81 / $3,984.81
| Facility | | $3,984.81 | $3,984.81 | $3,984.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,984.81 / $4,554.07 / $5,336.96
| Professional | | $3,984.81 | $4,554.07 | $5,336.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,261.93 / $7,261.93 / $7,261.93
| Facility | | $7,261.93 | $7,261.93 | $7,261.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,301.21 / $5,301.21 / $12,525.00
| Professional | | $5,301.21 | $5,301.21 | $12,525.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,978.39 / $5,577.97 / $48,028.87
| Facility | | $2,978.39 | $5,577.97 | $48,028.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,075.66 / $6,096.46 / $9,401.69
| Professional | | $3,075.66 | $6,096.46 | $9,401.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,075.66 / $4,439.91 / $6,949.58
| Professional | | $3,075.66 | $4,439.91 | $6,949.58 |