- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,365.39 / $2,365.39 / $2,365.39
| Facility | | $2,365.39 | $2,365.39 | $2,365.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,329.51 / $2,365.39 / $2,365.39
| Professional | | $2,329.51 | $2,365.39 | $2,365.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,365.02 / $9,205.07 / $11,506.33
| Professional | | $8,365.02 | $9,205.07 | $11,506.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,417.14 / $3,346.34 / $5,695.87
| Facility | | $1,417.14 | $3,346.34 | $5,695.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,651.06 / $3,947.13 / $17,297.04
| Professional | | $2,651.06 | $3,947.13 | $17,297.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,553.06 / $5,734.20 / $6,566.71
| Facility | | $3,553.06 | $5,734.20 | $6,566.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,283.21 / $5,211.07 / $6,566.71
| Professional | | $4,283.21 | $5,211.07 | $6,566.71 |
- 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
- $2,425.27 / $3,917.74 / $5,759.96
| Professional | | $2,425.27 | $3,917.74 | $5,759.96 |