- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,263.62 / $2,263.62 / $2,263.62
| Facility | | $2,263.62 | $2,263.62 | $2,263.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,263.62 / $2,487.23 / $22,150.00
| Professional | | $2,263.62 | $2,487.23 | $22,150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,391.66 / $4,391.66 / $4,391.66
| Facility | | $4,391.66 | $4,391.66 | $4,391.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,732.91 / $4,391.66 / $9,118.50
| Professional | | $3,732.91 | $4,391.66 | $9,118.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $5,816.58 / $7,561.55
| Professional | | $60.00 | $5,816.58 | $7,561.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,430.72 / $5,577.36 / $8,366.03
| Professional | | $4,430.72 | $5,577.36 | $8,366.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,165.89 / $3,506.32 / $5,030.26
| Professional | | $3,165.89 | $3,506.32 | $5,030.26 |