- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,760.77 / $2,760.77 / $2,760.77
| Facility | | $2,760.77 | $2,760.77 | $2,760.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,760.77 / $3,155.16 / $3,155.16
| Professional | | $2,760.77 | $3,155.16 | $3,155.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,865.01 / $4,865.01 / $4,865.01
| Facility | | $4,865.01 | $4,865.01 | $4,865.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,551.46 / $4,865.01 / $4,865.01
| Professional | | $3,551.46 | $4,865.01 | $4,865.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,988.15 / $3,864.56 / $33,007.53
| Facility | | $1,988.15 | $3,864.56 | $33,007.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.08 / $4,069.54 / $6,513.71
| Professional | | $2,053.08 | $4,069.54 | $6,513.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,320.94 / $5,320.94 / $5,320.94
| Facility | | $5,320.94 | $5,320.94 | $5,320.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.08 / $3,079.62 / $4,639.02
| Professional | | $2,053.08 | $3,079.62 | $4,639.02 |