- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,931.47 / $3,817.13 / $6,226.35
| Facility | | $1,931.47 | $3,817.13 | $6,226.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.25 / $1,526.85 / $1,877.85
| Professional | | $1,316.25 | $1,526.85 | $1,877.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,193.75 / $2,193.75 / $2,193.75
| Professional | | $2,193.75 | $2,193.75 | $2,193.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,723.80 / $3,194.10 / $3,979.50
| Facility | | $1,723.80 | $3,194.10 | $3,979.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,439.10 / $1,755.00 / $2,535.00
| Facility | | $1,439.10 | $1,755.00 | $2,535.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $1,053.00 / $9,711.00
| Professional | | $737.10 | $1,053.00 | $9,711.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $1,053.00 / $2,632.50
| Professional | | $737.10 | $1,053.00 | $2,632.50 |