- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $5,888.44
| Facility | | $5,888.44 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $2,398.83 / $2,511.89
| Professional | | $95.50 | $2,398.83 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $489.78 / $1,000.00
| Facility | | $204.17 | $489.78 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $234.42 / $446.68
| Professional | | $177.83 | $234.42 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.50 / $134.90 / $2,398.83
| Facility | | $95.50 | $134.90 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |