- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,438.81 / $2,438.81 / $2,438.81
| Facility | | $2,438.81 | $2,438.81 | $2,438.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.80 / $2,438.81 / $2,438.81
| Professional | | $1,905.80 | $2,438.81 | $2,438.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,787.87 / $5,013.35 / $5,570.40
| Professional | | $3,787.87 | $5,013.35 | $5,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,780.00 / $4,227.50 / $4,555.38
| Facility | | $1,780.00 | $4,227.50 | $4,555.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.13 / $4,327.60 / $4,555.38
| Professional | | $1,822.13 | $4,327.60 | $4,555.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,510.21 / $3,600.52 / $3,600.52
| Facility | | $3,510.21 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,637.94 / $3,427.94 / $3,600.52
| Professional | | $2,637.94 | $3,427.94 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.50 / $2,189.00 / $3,114.68
| Professional | | $1,347.50 | $2,189.00 | $3,114.68 |