- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.00 / $3,471.51 / $4,686.54
| Facility | | $1,897.00 | $3,471.51 | $4,686.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.63 / $1,498.63 / $2,181.55
| Professional | | $1,498.63 | $1,498.63 | $2,181.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,432.00 / $2,432.00 / $2,432.00
| Facility | | $2,432.00 | $2,432.00 | $2,432.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,432.00 / $2,432.00 / $2,432.00
| Professional | | $2,432.00 | $2,432.00 | $2,432.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.05 / $1,233.05 / $1,294.70
| Facility | | $1,233.05 | $1,233.05 | $1,294.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $1,138.20 / $3,238.12
| Professional | | $796.74 | $1,138.20 | $3,238.12 |