- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,875.00 / $1,875.00 / $1,875.00
| Facility | | $1,875.00 | $1,875.00 | $1,875.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.00 / $1,875.00 / $1,875.00
| Professional | | $1,875.00 | $1,875.00 | $1,875.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,325.48 / $3,297.84 / $7,933.39
| Facility | | $2,325.48 | $3,297.84 | $7,933.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,986.06 / $3,054.70 / $4,430.07
| Professional | | $1,986.06 | $3,054.70 | $4,430.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,890.46 / $3,015.01 / $6,246.76
| Facility | | $1,890.46 | $3,015.01 | $6,246.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.46 / $2,517.48 / $3,747.51
| Professional | | $1,652.46 | $2,517.48 | $3,747.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,875.00 / $3,168.75 / $8,152.00
| Facility | | $1,875.00 | $3,168.75 | $8,152.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.00 / $3,236.00 / $5,530.00
| Facility | | $1,445.00 | $3,236.00 | $5,530.00 |