- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,297.92 / $2,297.92 / $3,849.02
| Facility | | $2,297.92 | $2,297.92 | $3,849.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.13 / $2,425.86 / $3,835.75
| Professional | | $2,264.13 | $2,425.86 | $3,835.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,384.12 / $3,384.12 / $3,384.12
| Facility | | $3,384.12 | $3,384.12 | $3,384.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,384.12 / $3,384.12 / $3,384.12
| Professional | | $3,384.12 | $3,384.12 | $3,384.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.02 / $2,527.71 / $7,908.42
| Facility | | $798.02 | $2,527.71 | $7,908.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $5,149.20
| Professional | | $4,200.00 | $4,200.00 | $5,149.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $4,452.00
| Professional | | $4,200.00 | $4,200.00 | $4,452.00 |