- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,057.35 / $3,057.35 / $3,057.35
| Facility | | $3,057.35 | $3,057.35 | $3,057.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.20 / $3,057.35 / $3,615.87
| Professional | | $1,122.20 | $3,057.35 | $3,615.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,924.67 / $5,924.67 / $7,231.10
| Facility | | $5,924.67 | $5,924.67 | $7,231.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,427.64 / $6,427.64 / $6,427.64
| Professional | | $6,427.64 | $6,427.64 | $6,427.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,181.37 / $5,181.37 / $5,181.37
| Facility | | $5,181.37 | $5,181.37 | $5,181.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,290.22 / $4,885.35 / $20,185.68
| Professional | | $3,290.22 | $4,885.35 | $20,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.88 / $2,571.12 / $5,784.88
| Professional | | $1,516.88 | $2,571.12 | $5,784.88 |