- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,604.52 / $1,604.52 / $1,604.52
| Facility | | $1,604.52 | $1,604.52 | $1,604.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.39 / $1,604.52 / $1,604.52
| Professional | | $1,450.39 | $1,604.52 | $1,604.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,963.24 / $3,616.19 / $4,478.08
| Professional | | $2,963.24 | $3,616.19 | $4,478.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,074.06 / $2,451.16 / $2,711.64
| Facility | | $2,074.06 | $2,451.16 | $2,711.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.75 / $3,864.70 / $12,233.12
| Professional | | $2,282.75 | $3,864.70 | $12,233.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,744.37 / $3,011.33 / $4,924.47
| Facility | | $1,744.37 | $3,011.33 | $4,924.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,011.33 / $3,755.55 / $4,924.47
| Professional | | $3,011.33 | $3,755.55 | $4,924.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,759.89 / $3,494.45 / $5,435.81
| Professional | | $1,759.89 | $3,494.45 | $5,435.81 |