- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.29 / $1,640.29 / $1,640.29
| Facility | | $1,640.29 | $1,640.29 | $1,640.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.29 / $1,874.62 / $2,092.64
| Professional | | $1,640.29 | $1,874.62 | $2,092.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,297.39 / $3,297.39 / $3,297.39
| Facility | | $3,297.39 | $3,297.39 | $3,297.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.09 / $3,297.39 / $3,297.39
| Professional | | $2,407.09 | $3,297.39 | $3,297.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,231.29 / $2,296.09 / $19,929.31
| Facility | | $1,231.29 | $2,296.09 | $19,929.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.50 / $2,397.83 / $3,870.08
| Professional | | $1,271.50 | $2,397.83 | $3,870.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,332.71 / $4,332.71 / $4,332.71
| Facility | | $4,332.71 | $4,332.71 | $4,332.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.50 / $1,827.63 / $2,873.00
| Professional | | $1,271.50 | $1,827.63 | $2,873.00 |