- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,634.77 / $3,634.77 / $3,634.77
| Facility | | $3,634.77 | $3,634.77 | $3,634.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,634.77 / $4,154.02 / $4,154.02
| Professional | | $3,634.77 | $4,154.02 | $4,154.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,751.45 / $4,751.45 / $4,751.45
| Facility | | $4,751.45 | $4,751.45 | $4,751.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,038.73 / $4,751.45 / $4,751.45
| Professional | | $4,038.73 | $4,751.45 | $4,751.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.52 / $5,087.97 / $39,447.21
| Facility | | $2,571.52 | $5,087.97 | $39,447.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.05 / $5,012.97 / $8,575.81
| Professional | | $2,529.05 | $5,012.97 | $8,575.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.05 / $4,037.89 / $5,714.49
| Professional | | $2,529.05 | $4,037.89 | $5,714.49 |