- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,936.99 / $2,936.99 / $2,936.99
| Facility | | $2,936.99 | $2,936.99 | $2,936.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,616.79 / $2,936.99 / $2,936.99
| Professional | | $2,616.79 | $2,936.99 | $2,936.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,742.01 / $4,422.38 / $4,963.51
| Facility | | $3,742.01 | $4,422.38 | $4,963.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,119.46 / $6,985.58 / $22,396.80
| Professional | | $4,119.46 | $6,985.58 | $22,396.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,195.08 / $3,147.37 / $5,558.91
| Facility | | $1,195.08 | $3,147.37 | $5,558.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,843.93 / $3,843.93 / $13,876.02
| Professional | | $3,843.93 | $3,843.93 | $13,876.02 |
- 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
- $4,119.46 / $6,304.21 / $9,806.54
| Professional | | $4,119.46 | $6,304.21 | $9,806.54 |