- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,983.04 / $2,983.04 / $2,983.04
| Facility | | $2,983.04 | $2,983.04 | $2,983.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,983.04 / $3,352.62 / $3,409.18
| Professional | | $2,983.04 | $3,352.62 | $3,409.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,087.83 / $6,087.83 / $6,087.83
| Professional | | $6,087.83 | $6,087.83 | $6,087.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $4,052.23
| Facility | | $4,052.23 | $4,052.23 | $4,052.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $4,052.23 / $4,052.23
| Professional | | $2,958.13 | $4,052.23 | $4,052.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,797.85 / $4,175.68 / $29,802.90
| Facility | | $1,797.85 | $4,175.68 | $29,802.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,856.56 / $3,680.01 / $6,962.12
| Professional | | $1,856.56 | $3,680.01 | $6,962.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,856.56 / $3,134.89 / $4,194.97
| Professional | | $1,856.56 | $3,134.89 | $4,194.97 |