- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,349.55 / $4,170.46 / $5,537.50
| Facility | | $2,349.55 | $4,170.46 | $5,537.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,405.72 / $1,957.96 / $4,894.91
| Professional | | $1,405.72 | $1,957.96 | $4,894.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,117.55 / $2,510.21 / $3,137.76
| Facility | | $1,117.55 | $2,510.21 | $3,137.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $1,500.00 / $1,875.00
| Professional | | $1,500.00 | $1,500.00 | $1,875.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.64 / $2,936.95 / $9,088.23
| Facility | | $1,631.64 | $2,936.95 | $9,088.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.30 / $3,057.46 / $3,663.18
| Professional | | $2,231.30 | $3,057.46 | $3,663.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.54 / $2,510.21 / $2,635.72
| Professional | | $627.54 | $2,510.21 | $2,635.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,506.13 / $3,419.42
| Professional | | $1,054.29 | $1,506.13 | $3,419.42 |