- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,435.64 / $4,435.64 / $4,435.64
| Facility | | $4,435.64 | $4,435.64 | $4,435.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,435.64 / $5,069.32 / $5,117.20
| Professional | | $4,435.64 | $5,069.32 | $5,117.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,652.12 / $6,652.12 / $6,652.12
| Facility | | $6,652.12 | $6,652.12 | $6,652.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,856.05 / $6,652.12 / $6,652.12
| Professional | | $4,856.05 | $6,652.12 | $6,652.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.74 / $6,209.06 / $48,028.27
| Facility | | $2,970.74 | $6,209.06 | $48,028.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,067.77 / $6,080.81 / $10,465.40
| Professional | | $3,067.77 | $6,080.81 | $10,465.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,067.77 / $4,927.60 / $6,931.74
| Professional | | $3,067.77 | $4,927.60 | $6,931.74 |