- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.64 / $1,895.64 / $1,895.64
| Facility | | $1,895.64 | $1,895.64 | $1,895.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.64 / $2,166.44 / $2,339.06
| Professional | | $1,895.64 | $2,166.44 | $2,339.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,755.40 / $3,755.40 / $3,755.40
| Professional | | $3,755.40 | $3,755.40 | $3,755.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,632.35 / $3,868.66 / $3,868.66
| Professional | | $2,632.35 | $3,868.66 | $3,868.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $3,001.57
| Facility | | $3,001.57 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $3,001.57 / $3,001.57
| Professional | | $2,191.15 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,085.19 / $2,899.65 / $21,089.02
| Facility | | $2,085.19 | $2,899.65 | $21,089.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.73 / $2,609.96 / $4,472.53
| Professional | | $1,316.73 | $2,609.96 | $4,472.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.73 / $2,105.88 / $3,043.56
| Professional | | $1,316.73 | $2,105.88 | $3,043.56 |