- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,847.62 / $1,847.62 / $1,847.62
| Facility | | $1,847.62 | $1,847.62 | $1,847.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.62 / $1,847.62 / $3,074.00
| Professional | | $1,847.62 | $1,847.62 | $3,074.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,483.00 / $3,130.41 / $4,416.56
| Professional | | $2,483.00 | $3,130.41 | $4,416.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $3,476.28
| Facility | | $3,148.57 | $3,148.57 | $3,476.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $2,791.07 / $3,148.57
| Professional | | $2,298.46 | $2,791.07 | $3,148.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,837.88 / $3,022.20 / $6,486.32
| Facility | | $1,837.88 | $3,022.20 | $6,486.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,022.20 / $3,022.20 / $3,022.20
| Professional | | $3,022.20 | $3,022.20 | $3,022.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.44 / $2,060.46 / $3,104.50
| Professional | | $1,572.44 | $2,060.46 | $3,104.50 |