- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,205.54 / $3,205.54 / $3,205.54
| Facility | | $3,205.54 | $3,205.54 | $3,205.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,205.54 / $3,484.42 / $10,562.30
| Professional | | $3,205.54 | $3,484.42 | $10,562.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.81 / $3,660.81 / $3,660.81
| Facility | | $3,660.81 | $3,660.81 | $3,660.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.27 / $1,868.89 / $2,243.87
| Professional | | $1,607.27 | $1,868.89 | $2,243.87 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $2,745.60 / $2,745.60 / $2,745.60
| Professional | | $2,745.60 | $2,745.60 | $2,745.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.54 / $2,952.00 / $5,589.70
| Professional | | $1,978.54 | $2,952.00 | $5,589.70 |