- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.56 / $2,448.56 / $5,203.18
| Facility | | $2,448.56 | $2,448.56 | $5,203.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.33 / $1,983.33 / $1,983.33
| Professional | | $1,983.33 | $1,983.33 | $1,983.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.07 / $9.07 / $1,591.56
| Professional | | $9.07 | $9.07 | $1,591.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,448.56 / $2,448.56 / $2,473.05
| Professional | | $2,448.56 | $2,448.56 | $2,473.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.56 / $2,448.56 / $3,966.67
| Facility | | $2,448.56 | $2,448.56 | $3,966.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.33 / $1,983.33 / $2,448.56
| Professional | | $1,983.33 | $1,983.33 | $2,448.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.77 / $1,469.14 / $3,672.84
| Professional | | $1,248.77 | $1,469.14 | $3,672.84 |