- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,168.67 / $3,168.67 / $3,168.67
| Facility | | $3,168.67 | $3,168.67 | $3,168.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.23 / $2,206.03 / $3,529.65
| Professional | | $1,357.23 | $2,206.03 | $3,529.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,651.33 / $3,651.33 / $3,651.33
| Professional | | $3,651.33 | $3,651.33 | $3,651.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,741.63 / $6,537.66
| Professional | | $2,001.39 | $2,741.63 | $6,537.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.23 / $3,396.16 / $21,030.00
| Facility | | $1,357.23 | $3,396.16 | $21,030.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.55 / $2,412.85 / $5,383.66
| Professional | | $1,401.55 | $2,412.85 | $5,383.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.55 / $2,102.33 / $3,239.62
| Professional | | $1,401.55 | $2,102.33 | $3,239.62 |