- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,410.07 / $2,410.07 / $2,410.07
| Facility | | $2,410.07 | $2,410.07 | $2,410.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.22 / $1,769.09 / $2,410.07
| Professional | | $906.22 | $1,769.09 | $2,410.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,069.83 / $3,069.83 / $3,069.83
| Professional | | $3,069.83 | $3,069.83 | $3,069.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $1,350.00
| Facility | | $1,350.00 | $1,350.00 | $1,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.56 / $1,350.00 / $3,862.50
| Professional | | $209.56 | $1,350.00 | $3,862.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.22 / $2,256.23 / $14,590.13
| Facility | | $906.22 | $2,256.23 | $14,590.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.04 / $1,333.56 / $2,322.30
| Professional | | $889.04 | $1,333.56 | $2,322.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.04 / $1,333.56 / $2,369.19
| Professional | | $889.04 | $1,333.56 | $2,369.19 |