- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,462.78 / $1,462.78 / $1,462.78
| Facility | | $1,462.78 | $1,462.78 | $1,462.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,462.78 / $1,756.95
| Professional | | $1,393.12 | $1,462.78 | $1,756.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $2,340.00 / $2,700.23
| Professional | | $1,393.12 | $2,340.00 | $2,700.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,314.26 / $1,393.12 / $1,393.12
| Facility | | $1,314.26 | $1,393.12 | $1,393.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $1,393.12
| Professional | | $1,393.12 | $1,393.12 | $1,393.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,462.78 / $1,638.00 / $3,101.09
| Facility | | $1,462.78 | $1,638.00 | $3,101.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,638.00 / $1,638.00 / $1,638.00
| Professional | | $1,638.00 | $1,638.00 | $1,638.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.46 / $1,393.12 / $1,490.64
| Professional | | $1,323.46 | $1,393.12 | $1,490.64 |