- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,313.10 / $2,840.00 / $2,840.00
| Facility | | $1,313.10 | $2,840.00 | $2,840.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $2,840.00
| Professional | | $1,000.00 | $1,000.00 | $2,840.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,400.00 / $2,400.00 / $2,400.00
| Professional | | $2,400.00 | $2,400.00 | $2,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $495.11 / $1,883.48 / $2,543.03
| Facility | | $495.11 | $1,883.48 | $2,543.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.14 / $542.33 / $2,075.15
| Professional | | $258.14 | $542.33 | $2,075.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $609.10 / $1,179.06 / $2,496.75
| Professional | | $609.10 | $1,179.06 | $2,496.75 |