- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,639.81 / $5,639.81 / $5,639.81
| Facility | | $5,639.81 | $5,639.81 | $5,639.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,015.91 / $4,139.85 / $5,639.81
| Professional | | $2,015.91 | $4,139.85 | $5,639.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,071.91 / $5,071.91 / $5,071.91
| Professional | | $5,071.91 | $5,071.91 | $5,071.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,461.85 / $3,461.85 / $3,461.85
| Facility | | $3,461.85 | $3,461.85 | $3,461.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.13 / $3,461.85 / $9,196.87
| Professional | | $499.13 | $3,461.85 | $9,196.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,015.91 / $5,279.82 / $33,329.12
| Facility | | $2,015.91 | $5,279.82 | $33,329.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.12 / $3,120.18 / $5,270.36
| Professional | | $2,080.12 | $3,120.18 | $5,270.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.12 / $3,120.18 / $5,270.36
| Professional | | $2,080.12 | $3,120.18 | $5,270.36 |