- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,063.64 / $5,063.64 / $5,063.64
| Facility | | $5,063.64 | $5,063.64 | $5,063.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,063.64 / $5,787.02 / $5,787.02
| Professional | | $5,063.64 | $5,787.02 | $5,787.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,136.27 / $8,136.27 / $8,136.27
| Facility | | $8,136.27 | $8,136.27 | $8,136.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,939.48 / $8,136.27 / $8,136.27
| Professional | | $5,939.48 | $8,136.27 | $8,136.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,391.63 / $7,088.14 / $54,846.88
| Facility | | $3,391.63 | $7,088.14 | $54,846.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,502.40 / $6,942.32 / $11,525.09
| Professional | | $3,502.40 | $6,942.32 | $11,525.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,502.40 / $5,321.42 / $7,913.81
| Professional | | $3,502.40 | $5,321.42 | $7,913.81 |