- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,230.46 / $2,230.46 / $8,500.00
| Facility | | $2,230.46 | $2,230.46 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.75 / $2,230.46 / $3,087.00
| Professional | | $1,443.75 | $2,230.46 | $3,087.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,108.83 / $4,666.80 / $6,685.60
| Professional | | $3,108.83 | $4,666.80 | $6,685.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,312.50 / $2,290.41 / $4,126.37
| Facility | | $1,312.50 | $2,290.41 | $4,126.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.16 / $3,629.66 / $7,576.68
| Professional | | $2,068.16 | $3,629.66 | $7,576.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.00 / $681.00 / $681.00
| Facility | | $681.00 | $681.00 | $681.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.14 / $3,381.60 / $5,074.88
| Professional | | $1,961.14 | $3,381.60 | $5,074.88 |