- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,205.00 / $3,234.00 / $15,912.80
| Facility | | $2,205.00 | $3,234.00 | $15,912.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.88 / $2,499.00 / $3,307.50
| Professional | | $2,002.88 | $2,499.00 | $3,307.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,845.70 / $2,629.17 / $13,818.28
| Facility | | $1,845.70 | $2,629.17 | $13,818.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,940.00 / $4,476.30 / $5,363.11
| Professional | | $2,940.00 | $4,476.30 | $5,363.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.00 / $2,205.00 / $3,123.75
| Professional | | $2,205.00 | $2,205.00 | $3,123.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,323.00 / $2,205.00 / $3,307.50
| Facility | | $1,323.00 | $2,205.00 | $3,307.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.25 / $1,543.50 / $8,085.00
| Professional | | $1,286.25 | $1,543.50 | $8,085.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.00 / $2,205.00 / $2,205.00
| Professional | | $2,205.00 | $2,205.00 | $2,205.00 |