- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,233.09 / $2,233.09 / $2,233.09
| Facility | | $2,233.09 | $2,233.09 | $2,233.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.93 / $2,233.09 / $3,205.54
| Professional | | $1,395.93 | $2,233.09 | $3,205.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,468.05 / $7,468.05 / $7,468.05
| Facility | | $7,468.05 | $7,468.05 | $7,468.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,787.53 / $2,787.53 / $2,787.53
| Professional | | $2,787.53 | $2,787.53 | $2,787.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.00 / $1,700.00 / $1,700.00
| Professional | | $1,700.00 | $1,700.00 | $1,700.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,686.04 / $3,193.32 / $4,122.54
| Facility | | $1,686.04 | $3,193.32 | $4,122.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.09 / $1,454.09 / $1,454.09
| Professional | | $1,454.09 | $1,454.09 | $1,454.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,928.65 / $4,759.05 / $6,882.32
| Professional | | $2,928.65 | $4,759.05 | $6,882.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.34 / $3,813.92 / $5,727.34
| Professional | | $1,826.34 | $3,813.92 | $5,727.34 |