- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,301.65 / $2,301.65 / $2,301.65
| Facility | | $2,301.65 | $2,301.65 | $2,301.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $600.00 / $2,301.65
| Professional | | $600.00 | $600.00 | $2,301.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,881.64 / $4,881.64 / $4,881.64
| Facility | | $4,881.64 | $4,881.64 | $4,881.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,813.77 / $4,447.53 / $5,559.41
| Professional | | $2,813.77 | $4,447.53 | $5,559.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,310.94 / $2,772.51 / $11,630.66
| Facility | | $2,310.94 | $2,772.51 | $11,630.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.07 / $1,469.14 / $4,489.68
| Professional | | $307.07 | $1,469.14 | $4,489.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.40 / $3,183.13 / $5,366.23
| Facility | | $975.40 | $3,183.13 | $5,366.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.40 / $3,196.38 / $6,390.74
| Professional | | $975.40 | $3,196.38 | $6,390.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,448.56 / $5,899.32 / $6,726.68
| Professional | | $2,448.56 | $5,899.32 | $6,726.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.07 / $1,028.40 / $2,448.56
| Professional | | $307.07 | $1,028.40 | $2,448.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,448.56 / $2,448.56 / $2,448.56
| Professional | | $2,448.56 | $2,448.56 | $2,448.56 |