- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,490.12 / $2,490.12 / $2,490.12
| Facility | | $2,490.12 | $2,490.12 | $2,490.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.17 / $2,490.12 / $2,490.12
| Professional | | $1,437.17 | $2,490.12 | $2,490.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,312.06 / $2,312.06 / $2,312.06
| Professional | | $2,312.06 | $2,312.06 | $2,312.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,950.00 / $1,950.00 / $1,950.00
| Facility | | $1,950.00 | $1,950.00 | $1,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.82 / $1,950.00 / $3,611.25
| Professional | | $244.82 | $1,950.00 | $3,611.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.55 / $1,253.32 / $2,412.83
| Professional | | $835.55 | $1,253.32 | $2,412.83 |