- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,002.09 / $3,002.09 / $6,379.44
| Facility | | $3,002.09 | $3,002.09 | $6,379.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $2,431.69 / $2,431.69
| Professional | | $1,500.00 | $2,431.69 | $2,431.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.83 / $1,320.92 / $2,877.60
| Professional | | $1,200.83 | $1,320.92 | $2,877.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,403.39 / $6,403.39 / $6,403.39
| Facility | | $6,403.39 | $6,403.39 | $6,403.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,002.09 / $3,002.09 / $3,032.11
| Professional | | $3,002.09 | $3,002.09 | $3,032.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,002.09 / $3,002.09 / $4,863.39
| Facility | | $3,002.09 | $3,002.09 | $4,863.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.69 / $2,431.69 / $3,002.09
| Professional | | $2,431.69 | $2,431.69 | $3,002.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.05 / $1,801.25 / $4,503.14
| Professional | | $1,501.05 | $1,801.25 | $4,503.14 |