- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $3,567.38
| Facility | | $1,902.62 | $1,902.62 | $3,567.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $2,038.50
| Professional | | $1,902.62 | $1,902.62 | $2,038.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,038.51 / $2,211.59 / $2,623.50
| Professional | | $2,038.51 | $2,211.59 | $2,623.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Facility | | $1,902.62 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.84 / $6,650.73 / $8,437.50
| Facility | | $2,530.84 | $6,650.73 | $8,437.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,450.00 / $10,260.00 / $10,463.36
| Professional | | $9,450.00 | $10,260.00 | $10,463.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.52 / $1,902.62 / $1,902.62
| Professional | | $1,826.52 | $1,902.62 | $1,902.62 |