- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,112.98 / $3,112.98 / $3,112.98
| Facility | | $3,112.98 | $3,112.98 | $3,112.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,112.98 / $3,557.69 / $3,557.69
| Professional | | $3,112.98 | $3,557.69 | $3,557.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,353.02 / $6,353.02 / $6,353.02
| Professional | | $6,353.02 | $6,353.02 | $6,353.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,790.37 / $3,790.37 / $3,790.37
| Facility | | $3,790.37 | $3,790.37 | $3,790.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.97 / $3,790.37 / $3,790.37
| Professional | | $2,766.97 | $3,790.37 | $3,790.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,953.69 / $4,357.58 / $32,412.74
| Facility | | $1,953.69 | $4,357.58 | $32,412.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.50 / $3,999.01 / $7,344.71
| Professional | | $2,017.50 | $3,999.01 | $7,344.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.50 / $3,458.23 / $4,558.62
| Professional | | $2,017.50 | $3,458.23 | $4,558.62 |