- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,105.57 / $3,105.57 / $3,105.57
| Facility | | $3,105.57 | $3,105.57 | $3,105.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.20 / $2,162.11 / $3,459.37
| Professional | | $1,330.20 | $2,162.11 | $3,459.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,041.64 / $5,041.64 / $5,041.64
| Professional | | $5,041.64 | $5,041.64 | $5,041.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $3,148.57
| Facility | | $3,148.57 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $3,148.57 / $6,389.53
| Professional | | $2,298.46 | $3,148.57 | $6,389.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,330.20 / $3,328.54 / $20,548.93
| Facility | | $1,330.20 | $3,328.54 | $20,548.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.64 / $2,364.80 / $5,276.48
| Professional | | $1,373.64 | $2,364.80 | $5,276.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.64 / $2,060.46 / $3,175.12
| Professional | | $1,373.64 | $2,060.46 | $3,175.12 |