- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,388.44
| Facility | | $2,951.21 | $2,951.21 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,995.26 / $3,388.44
| Professional | | $1,445.44 | $1,995.26 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,466.84 / $4,897.79
| Professional | | $3,388.44 | $4,466.84 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $5,888.44
| Professional | | $4,677.35 | $4,677.35 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,548.13 / $17,378.01
| Facility | | $1,698.24 | $3,548.13 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,041.74 / $3,890.45
| Professional | | $1,479.11 | $2,041.74 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,370.32 / $5,370.32
| Facility | | $2,187.76 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,454.71 / $4,365.16
| Professional | | $1,288.25 | $2,454.71 | $4,365.16 |