- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,491.75 / $2,359.50 / $4,071.60
| Facility | | $1,491.75 | $2,359.50 | $4,071.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.75 / $1,526.85 / $2,018.25
| Professional | | $1,491.75 | $1,526.85 | $2,018.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.05 / $1,561.91 / $3,108.38
| Professional | | $895.05 | $1,561.91 | $3,108.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,685.83 / $3,765.74 / $4,647.92
| Facility | | $2,685.83 | $3,765.74 | $4,647.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.92 / $2,262.92 / $2,262.92
| Professional | | $2,262.92 | $2,262.92 | $2,262.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.85 / $2,290.28 / $9,262.50
| Facility | | $1,526.85 | $2,290.28 | $9,262.50 |
- 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 / $2,106.00
| Professional | | $737.10 | $1,053.00 | $2,106.00 |