- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,177.65 / $3,177.65 / $3,177.65
| Facility | | $3,177.65 | $3,177.65 | $3,177.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.53 / $2,081.91 / $3,177.65
| Professional | | $1,109.53 | $2,081.91 | $3,177.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,392.66 / $3,582.25 / $3,926.22
| Facility | | $3,392.66 | $3,582.25 | $3,926.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,710.84 / $3,710.84 / $3,710.84
| Professional | | $3,710.84 | $3,710.84 | $3,710.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $2,326.75
| Facility | | $2,326.75 | $2,326.75 | $2,326.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $2,326.75 / $5,588.44
| Professional | | $1,698.53 | $2,326.75 | $5,588.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,109.53 / $3,092.62 / $17,957.82
| Facility | | $1,109.53 | $3,092.62 | $17,957.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.77 / $1,914.43 / $4,902.47
| Professional | | $1,145.77 | $1,914.43 | $4,902.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.77 / $1,829.08 / $2,564.03
| Professional | | $1,145.77 | $1,829.08 | $2,564.03 |