- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,920.30 / $2,920.30 / $2,920.30
| Facility | | $2,920.30 | $2,920.30 | $2,920.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,920.30 / $3,049.36 / $27,156.00
| Professional | | $2,920.30 | $3,049.36 | $27,156.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,553.03 / $6,553.03 / $6,553.03
| Facility | | $6,553.03 | $6,553.03 | $6,553.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.71 / $6,553.03 / $6,749.62
| Professional | | $4,783.71 | $6,553.03 | $6,749.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $7,075.83 / $9,198.57
| Professional | | $60.00 | $7,075.83 | $9,198.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,487.17 / $9,465.41 / $9,465.41
| Facility | | $8,487.17 | $9,465.41 | $9,465.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,389.94 / $6,784.81 / $10,177.20
| Professional | | $5,389.94 | $6,784.81 | $10,177.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,084.33 / $4,523.51 / $6,489.56
| Professional | | $4,084.33 | $4,523.51 | $6,489.56 |