- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,022.09 / $3,022.09 / $3,022.09
| Facility | | $3,022.09 | $3,022.09 | $3,022.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.88 / $3,022.09 / $3,022.09
| Professional | | $1,534.88 | $3,022.09 | $3,022.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,055.85 / $3,055.85 / $3,055.85
| Professional | | $3,055.85 | $3,055.85 | $3,055.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,247.58 / $2,247.58 / $2,247.58
| Professional | | $2,247.58 | $2,247.58 | $2,247.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.07 / $2,160.07 / $4,119.22
| Facility | | $2,160.07 | $2,160.07 | $4,119.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.85 / $2,160.07 / $3,606.94
| Professional | | $1,576.85 | $2,160.07 | $3,606.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.74 / $1,793.56 / $2,657.57
| Professional | | $1,149.74 | $1,793.56 | $2,657.57 |