- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $1,751.72
| Facility | | $1,751.72 | $1,751.72 | $1,751.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $2,550.00
| Professional | | $1,751.72 | $1,751.72 | $2,550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.00 / $1,844.50 / $1,844.50
| Professional | | $1,300.00 | $1,844.50 | $1,844.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.89 / $3,528.38 / $6,786.10
| Facility | | $542.89 | $3,528.38 | $6,786.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.36 / $81.36 / $81.36
| Facility | | $81.36 | $81.36 | $81.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.67 / $783.67 / $783.67
| Professional | | $783.67 | $783.67 | $783.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |