- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.08 / $3,548.08 / $3,548.08
| Facility | | $3,548.08 | $3,548.08 | $3,548.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,264.71 / $3,548.08 / $3,548.08
| Professional | | $3,264.71 | $3,548.08 | $3,548.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,413.51 / $6,478.47 / $8,017.91
| Professional | | $6,413.51 | $6,478.47 | $8,017.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,668.54 / $5,517.36 / $14,857.52
| Facility | | $4,668.54 | $5,517.36 | $14,857.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,281.80 / $7,256.70 / $28,924.00
| Professional | | $4,281.80 | $7,256.70 | $28,924.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,041.51 / $8,951.98 / $11,909.16
| Facility | | $6,041.51 | $8,951.98 | $11,909.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,801.39 / $7,460.94 / $9,996.87
| Professional | | $4,801.39 | $7,460.94 | $9,996.87 |
- 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
- $4,793.17 / $6,541.42 / $10,175.54
| Professional | | $4,793.17 | $6,541.42 | $10,175.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,936.45 / $4,936.45 / $4,936.45
| Professional | | $4,936.45 | $4,936.45 | $4,936.45 |