- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,560.00 / $2,343.64 / $2,343.64
| Facility | | $1,560.00 | $2,343.64 | $2,343.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $32.50 / $2,057.64
| Professional | | $30.00 | $32.50 | $2,057.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.78 / $1,765.40 / $2,337.40
| Professional | | $1,053.78 | $1,765.40 | $2,337.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.00 / $2,000.00 / $2,713.75
| Professional | | $1,125.00 | $2,000.00 | $2,713.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $66.00 / $99.00
| Professional | | $50.00 | $66.00 | $99.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.72 / $569.20 / $724.43
| Professional | | $513.72 | $569.20 | $724.43 |