- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,014.56 / $3,014.56 / $3,014.56
| Facility | | $3,014.56 | $3,014.56 | $3,014.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,014.56 / $3,335.66 / $6,153.66
| Professional | | $3,014.56 | $3,335.66 | $6,153.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.53 / $2,673.00 / $3,207.60
| Professional | | $378.53 | $2,673.00 | $3,207.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.78 / $3,541.58 / $6,153.66
| Facility | | $497.78 | $3,541.58 | $6,153.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.84 / $322.13 / $3,177.18
| Professional | | $198.84 | $322.13 | $3,177.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.24 / $2,093.23 / $3,422.54
| Professional | | $1,783.24 | $2,093.23 | $3,422.54 |