- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,325.00 / $3,650.50 / $9,737.70
| Facility | | $3,325.00 | $3,650.50 | $9,737.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,855.00 / $2,301.25 / $2,450.00
| Professional | | $1,855.00 | $2,301.25 | $2,450.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.83 / $4,242.35 / $8,662.50
| Facility | | $274.83 | $4,242.35 | $8,662.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.25 / $2,100.00 / $4,887.05
| Professional | | $1,517.25 | $2,100.00 | $4,887.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,503.50 / $7,489.46 / $14,293.16
| Facility | | $3,503.50 | $7,489.46 | $14,293.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,025.00 / $6,377.00 / $8,645.00
| Professional | | $4,025.00 | $6,377.00 | $8,645.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.00 / $2,100.00 / $6,142.15
| Professional | | $1,470.00 | $2,100.00 | $6,142.15 |