- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,437.69 / $2,096.56 / $3,000.00
| Facility | | $1,437.69 | $2,096.56 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.78 / $2,096.56 / $2,147.08
| Professional | | $2,020.78 | $2,096.56 | $2,147.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $811.27 / $2,147.08 / $2,147.08
| Facility | | $811.27 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Professional | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,323.90 / $2,323.90 / $2,323.90
| Facility | | $2,323.90 | $2,323.90 | $2,323.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.10 / $2,323.90 / $2,323.90
| Professional | | $320.10 | $2,323.90 | $2,323.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $4,159.78
| Professional | | $50.00 | $50.00 | $4,159.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.98 / $2,104.98 / $2,210.23
| Professional | | $2,104.98 | $2,104.98 | $2,210.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,463.33 / $2,463.33 / $2,463.33
| Professional | | $2,463.33 | $2,463.33 | $2,463.33 |