- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,007.00 / $2,007.00 / $2,007.00
| Facility | | $2,007.00 | $2,007.00 | $2,007.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.36 / $2,033.76 / $2,721.44
| Professional | | $1,632.36 | $2,033.76 | $2,721.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,009.39 / $2,529.44 / $3,035.34
| Professional | | $2,009.39 | $2,529.44 | $3,035.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.00 / $2,160.00 / $2,160.00
| Facility | | $2,160.00 | $2,160.00 | $2,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.00 / $2,160.00 / $2,904.98
| Professional | | $1,836.00 | $2,160.00 | $2,904.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,966.44 / $15,669.80 / $16,241.11
| Facility | | $3,966.44 | $15,669.80 | $16,241.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.38 / $1,224.70 / $1,892.06
| Professional | | $925.38 | $1,224.70 | $1,892.06 |