- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,773.80 / $3,773.80 / $3,773.80
| Facility | | $3,773.80 | $3,773.80 | $3,773.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,773.80 / $4,312.92 / $4,312.92
| Professional | | $3,773.80 | $4,312.92 | $4,312.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,541.83 / $6,541.83 / $6,541.83
| Facility | | $6,541.83 | $6,541.83 | $6,541.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $6,541.83 / $6,541.83
| Professional | | $4,775.54 | $6,541.83 | $6,541.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,579.84 / $5,282.61 / $42,519.53
| Facility | | $2,579.84 | $5,282.61 | $42,519.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,664.10 / $5,280.66 / $8,903.85
| Professional | | $2,664.10 | $5,280.66 | $8,903.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,078.09 / $9,078.09 / $9,078.09
| Facility | | $9,078.09 | $9,078.09 | $9,078.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,664.10 / $3,996.14 / $6,020.97
| Professional | | $2,664.10 | $3,996.14 | $6,020.97 |