- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,002.09 / $3,452.40 / $6,004.18
| Facility | | $3,002.09 | $3,452.40 | $6,004.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $1,500.00 / $1,500.00
| Professional | | $1,500.00 | $1,500.00 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.89 / $652.76 / $878.17
| Facility | | $537.89 | $652.76 | $878.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.44 / $2,491.50 / $2,939.97
| Professional | | $1,695.44 | $2,491.50 | $2,939.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,912.33 / $2,439.19 / $6,498.03
| Facility | | $1,912.33 | $2,439.19 | $6,498.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,401.67 / $2,401.67 / $2,401.67
| Professional | | $2,401.67 | $2,401.67 | $2,401.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,260.88 / $3,002.09
| Professional | | $1,260.88 | $1,260.88 | $3,002.09 |