- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,616.59 / $1,616.59 / $1,616.59
| Facility | | $1,616.59 | $1,616.59 | $1,616.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.75 / $1,486.84 / $1,616.59
| Professional | | $974.75 | $1,486.84 | $1,616.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,247.72 / $3,526.99 / $4,408.72
| Professional | | $3,247.72 | $3,526.99 | $4,408.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,117.14 / $2,135.85 / $3,892.76
| Facility | | $1,117.14 | $2,135.85 | $3,892.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,605.06 / $2,804.78 / $11,040.16
| Professional | | $1,605.06 | $2,804.78 | $11,040.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.30 / $3,659.93 / $4,733.43
| Facility | | $2,428.30 | $3,659.93 | $4,733.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,733.81 / $3,799.48 / $4,733.43
| Professional | | $2,733.81 | $3,799.48 | $4,733.43 |
- 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
- $1,468.53 / $2,454.69 / $3,818.42
| Professional | | $1,468.53 | $2,454.69 | $3,818.42 |