- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,104.39 / $3,104.39 / $3,104.39
| Facility | | $3,104.39 | $3,104.39 | $3,104.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,104.39 / $3,547.87 / $3,581.42
| Professional | | $3,104.39 | $3,547.87 | $3,581.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,063.89 / $4,063.89 / $4,063.89
| Facility | | $4,063.89 | $4,063.89 | $4,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.31 / $4,063.89 / $4,063.89
| Professional | | $3,454.31 | $4,063.89 | $4,063.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,094.67 / $4,345.56 / $31,266.85
| Facility | | $2,094.67 | $4,345.56 | $31,266.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,163.08 / $4,287.58 / $7,324.45
| Professional | | $2,163.08 | $4,287.58 | $7,324.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.41 / $3,448.70 / $4,887.57
| Professional | | $2,406.41 | $3,448.70 | $4,887.57 |