- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $1,905.46
| Professional | | $1,000.00 | $1,288.25 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,623.41 / $6,309.57
| Facility | | $3,981.07 | $5,623.41 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $2,398.83
| Professional | | $1,548.82 | $1,819.70 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Facility | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $1,584.89
| Professional | | $851.14 | $1,348.96 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $4,365.16
| Professional | | $2,398.83 | $3,019.95 | $4,365.16 |