- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,607.66 / $3,607.66 / $5,279.51
| Facility | | $3,607.66 | $3,607.66 | $5,279.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,607.66 / $5,279.51 / $5,939.45
| Professional | | $3,607.66 | $5,279.51 | $5,939.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.86 / $401.86 / $401.86
| Professional | | $401.86 | $401.86 | $401.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $820.56 / $3,739.65 / $3,739.65
| Facility | | $820.56 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Professional | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,519.68 / $3,666.33 / $4,766.22
| Professional | | $3,519.68 | $3,666.33 | $4,766.22 |