- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,630.18 / $1,630.18 / $1,630.18
| Facility | | $1,630.18 | $1,630.18 | $1,630.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.18 / $1,630.18 / $76,542.00
| Professional | | $1,630.18 | $1,630.18 | $76,542.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,493.06 / $2,164.52 / $3,798.60
| Facility | | $1,493.06 | $2,164.52 | $3,798.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,630.18 / $1,630.18 / $2,934.32
| Facility | | $1,630.18 | $1,630.18 | $2,934.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,997.62 / $15,997.62 / $15,997.62
| Professional | | $15,997.62 | $15,997.62 | $15,997.62 |