- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,241.73 / $2,241.73 / $4,755.24
| Facility | | $2,241.73 | $2,241.73 | $4,755.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,241.73 / $2,241.73 / $4,755.24
| Professional | | $2,241.73 | $2,241.73 | $4,755.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,298.10 / $7,298.10 / $7,298.10
| Professional | | $7,298.10 | $7,298.10 | $7,298.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,935.40 / $3,782.85 / $18,920.00
| Professional | | $2,935.40 | $3,782.85 | $18,920.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,956.94 / $2,845.14 / $9,072.66
| Professional | | $1,956.94 | $2,845.14 | $9,072.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $7,875.00
| Professional | | $1,000.00 | $1,000.00 | $7,875.00 |