- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,159.42 / $3,159.42 / $6,713.77
| Facility | | $3,159.42 | $3,159.42 | $6,713.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.00 / $477.00 / $477.00
| Professional | | $477.00 | $477.00 | $477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.77 / $1,263.77 / $2,053.62
| Professional | | $1,263.77 | $1,263.77 | $2,053.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,159.42 / $3,159.42 / $3,191.01
| Professional | | $3,159.42 | $3,159.42 | $3,191.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,159.42 / $3,159.42 / $5,118.26
| Facility | | $3,159.42 | $3,159.42 | $5,118.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.00 / $477.00 / $3,159.42
| Professional | | $477.00 | $477.00 | $3,159.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.65 / $1,895.65 / $4,739.13
| Professional | | $1,895.65 | $1,895.65 | $4,739.13 |