- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,435.00 / $2,435.00 / $5,174.38
| Facility | | $2,435.00 | $2,435.00 | $5,174.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.35 / $1,972.35 / $1,972.35
| Professional | | $1,972.35 | $1,972.35 | $1,972.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.34 / $121.34 / $1,582.75
| Professional | | $121.34 | $121.34 | $1,582.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,435.00 / $2,435.00 / $2,459.35
| Professional | | $2,435.00 | $2,435.00 | $2,459.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,435.00 / $2,435.00 / $3,944.70
| Facility | | $2,435.00 | $2,435.00 | $3,944.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.35 / $1,972.35 / $2,435.00
| Professional | | $1,972.35 | $1,972.35 | $2,435.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.00 / $1,461.00 / $3,652.50
| Professional | | $1,461.00 | $1,461.00 | $3,652.50 |