- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,263.12 / $4,263.12 / $4,263.12
| Facility | | $4,263.12 | $4,263.12 | $4,263.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,263.12 / $4,897.37 / $9,283.07
| Professional | | $4,263.12 | $4,897.37 | $9,283.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.88 / $5,470.13 / $5,470.13
| Professional | | $585.88 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,263.12 / $5,482.13 / $9,283.07
| Facility | | $4,263.12 | $5,482.13 | $9,283.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.18 / $745.45 / $745.45
| Professional | | $708.18 | $745.45 | $745.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.57 / $461.97 / $4,501.06
| Professional | | $337.57 | $461.97 | $4,501.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,763.88 / $2,960.16 / $4,848.49
| Professional | | $2,763.88 | $2,960.16 | $4,848.49 |