- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,736.62 / $2,736.62 / $3,420.78
| Facility | | $2,736.62 | $2,736.62 | $3,420.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,420.78 / $3,420.78 / $3,591.82
| Facility | | $3,420.78 | $3,420.78 | $3,591.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,420.78 / $3,420.78 / $3,420.78
| Professional | | $3,420.78 | $3,420.78 | $3,420.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,420.78 / $3,694.44 / $4,426.35
| Professional | | $3,420.78 | $3,694.44 | $4,426.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.00 / $597.00 / $74,999.25
| Facility | | $555.00 | $597.00 | $74,999.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,894.96 / $3,626.03 / $4,426.35
| Professional | | $2,894.96 | $3,626.03 | $4,426.35 |