- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,905.46 / $2,905.46 / $2,905.46
| Facility | | $2,905.46 | $2,905.46 | $2,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,905.46 / $3,320.53 / $3,320.53
| Professional | | $2,905.46 | $3,320.53 | $3,320.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,366.38 / $4,366.38 / $4,366.38
| Facility | | $4,366.38 | $4,366.38 | $4,366.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.46 / $4,366.38 / $4,366.38
| Professional | | $3,187.46 | $4,366.38 | $4,366.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,005.72 / $4,067.10 / $33,390.44
| Facility | | $2,005.72 | $4,067.10 | $33,390.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,071.23 / $4,105.50 / $6,855.11
| Professional | | $2,071.23 | $4,105.50 | $6,855.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,071.23 / $3,148.52 / $4,680.02
| Professional | | $2,071.23 | $3,148.52 | $4,680.02 |