- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,936.64 / $2,936.64 / $2,936.64
| Facility | | $2,936.64 | $2,936.64 | $2,936.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,936.64 / $3,284.81 / $6,226.43
| Professional | | $2,936.64 | $3,284.81 | $6,226.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $3,626.76
| Facility | | $3,626.76 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.52 / $3,626.76 / $3,626.76
| Professional | | $387.52 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,936.64 / $3,747.26 / $6,226.43
| Facility | | $2,936.64 | $3,747.26 | $6,226.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.41 / $493.06 / $493.06
| Professional | | $468.41 | $493.06 | $493.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.78 / $313.19 / $2,288.79
| Professional | | $97.78 | $313.19 | $2,288.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.92 / $2,039.08 / $3,287.95
| Professional | | $1,853.92 | $2,039.08 | $3,287.95 |