- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,398.83 / $3,548.13
| Professional | | $2,089.30 | $2,398.83 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $2,398.83 / $5,011.87
| Professional | | $257.04 | $2,398.83 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,344.23 / $3,548.13
| Facility | | $2,089.30 | $2,344.23 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,513.56 / $2,818.38
| Professional | | $812.83 | $1,513.56 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $354.81 / $2,290.87
| Facility | | $162.18 | $354.81 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,479.11 / $2,398.83
| Professional | | $812.83 | $1,479.11 | $2,398.83 |