- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,996.68 / $2,996.68 / $2,996.68
| Facility | | $2,996.68 | $2,996.68 | $2,996.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,996.68 / $2,996.68 / $3,495.46
| Professional | | $2,996.68 | $2,996.68 | $3,495.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,999.07 / $8,305.75 / $10,965.48
| Facility | | $3,999.07 | $8,305.75 | $10,965.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,972.31 / $4,306.68 / $7,382.89
| Professional | | $3,972.31 | $4,306.68 | $7,382.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,728.96 / $4,728.96 / $8,453.62
| Facility | | $4,728.96 | $4,728.96 | $8,453.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $4,728.96 / $35,431.68
| Professional | | $3,452.14 | $4,728.96 | $35,431.68 |
- 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
- $3,048.83 / $4,258.93 / $5,104.20
| Professional | | $3,048.83 | $4,258.93 | $5,104.20 |