- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,769.18 / $2,769.18 / $2,769.18
| Facility | | $2,769.18 | $2,769.18 | $2,769.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.18 / $2,769.18 / $3,945.71
| Professional | | $2,769.18 | $2,769.18 | $3,945.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,386.03 / $2,386.03 / $2,386.03
| Facility | | $2,386.03 | $2,386.03 | $2,386.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,350.28 / $2,350.28 / $2,350.28
| Professional | | $2,350.28 | $2,350.28 | $2,350.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,053.00 / $4,457.18 / $6,668.25
| Facility | | $3,053.00 | $4,457.18 | $6,668.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,974.63 / $5,422.28 / $10,814.16
| Professional | | $2,974.63 | $5,422.28 | $10,814.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,203.45 / $5,372.81 / $10,123.35
| Professional | | $3,203.45 | $5,372.81 | $10,123.35 |