- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,392.76 / $3,392.76 / $3,392.76
| Facility | | $3,392.76 | $3,392.76 | $3,392.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,392.76 / $3,877.43 / $3,914.10
| Professional | | $3,392.76 | $3,877.43 | $3,914.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,391.66 / $4,391.66 / $4,391.66
| Facility | | $4,391.66 | $4,391.66 | $4,391.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,732.91 / $4,391.66 / $4,391.66
| Professional | | $3,732.91 | $4,391.66 | $4,391.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,263.62 / $4,749.21 / $33,788.62
| Facility | | $2,263.62 | $4,749.21 | $33,788.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.54 / $4,633.38 / $8,004.80
| Professional | | $2,337.54 | $4,633.38 | $8,004.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.54 / $3,740.07 / $5,281.77
| Professional | | $2,337.54 | $3,740.07 | $5,281.77 |