- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,922.31 / $1,922.31 / $1,922.31
| Facility | | $1,922.31 | $1,922.31 | $1,922.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.54 / $1,922.31 / $1,922.31
| Professional | | $1,472.54 | $1,922.31 | $1,922.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,903.80 / $3,903.80 / $3,931.82
| Professional | | $3,903.80 | $3,903.80 | $3,931.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,105.73 / $2,488.59 / $4,628.85
| Facility | | $2,105.73 | $2,488.59 | $4,628.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.40 / $2,849.62 / $12,381.76
| Professional | | $1,372.40 | $2,849.62 | $12,381.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,186.96 / $4,353.26 / $5,211.03
| Facility | | $3,186.96 | $4,353.26 | $5,211.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.75 / $4,294.91 / $5,211.03
| Professional | | $3,251.75 | $4,294.91 | $5,211.03 |
- 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
- $1,372.40 / $2,849.62 / $4,432.74
| Professional | | $1,372.40 | $2,849.62 | $4,432.74 |