- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,005.27 / $3,005.27 / $3,005.27
| Facility | | $3,005.27 | $3,005.27 | $3,005.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,005.27 / $3,434.60 / $3,434.60
| Professional | | $3,005.27 | $3,434.60 | $3,434.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,728.96 / $4,728.96 / $4,728.96
| Facility | | $4,728.96 | $4,728.96 | $4,728.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $4,728.96 / $4,728.96
| Professional | | $3,452.14 | $4,728.96 | $4,728.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,968.27 / $4,206.81 / $34,402.54
| Facility | | $1,968.27 | $4,206.81 | $34,402.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.55 / $4,028.84 / $7,090.58
| Professional | | $2,032.55 | $4,028.84 | $7,090.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,926.06 / $6,926.06 / $6,926.06
| Facility | | $6,926.06 | $6,926.06 | $6,926.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.55 / $3,158.26 / $4,592.63
| Professional | | $2,032.55 | $3,158.26 | $4,592.63 |