- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,786.30 / $7,762.47
| Professional | | $3,801.89 | $4,786.30 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $9,772.37
| Professional | | $4,786.30 | $4,786.30 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,495.41 / $26,915.35
| Facility | | $3,801.89 | $5,495.41 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,011.87 / $11,481.54
| Professional | | $2,691.53 | $5,011.87 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,079.46 / $9,332.54
| Facility | | $3,801.89 | $7,079.46 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,981.07 / $6,025.60
| Professional | | $2,691.53 | $3,981.07 | $6,025.60 |