- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,234.12 / $4,194.79 / $6,481.79
| Facility | | $2,234.12 | $4,194.79 | $6,481.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,624.00 / $1,766.10 / $2,172.10
| Professional | | $1,624.00 | $1,766.10 | $2,172.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,537.50 / $2,537.50 / $2,537.50
| Professional | | $2,537.50 | $2,537.50 | $2,537.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.52 / $3,325.14 / $4,602.67
| Facility | | $1,794.52 | $3,325.14 | $4,602.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,624.00 / $2,030.00 / $2,730.98
| Facility | | $1,624.00 | $2,030.00 | $2,730.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.60 / $1,218.00 / $10,109.40
| Professional | | $852.60 | $1,218.00 | $10,109.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,030.00 / $2,030.00 / $2,537.50
| Facility | | $2,030.00 | $2,030.00 | $2,537.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.60 / $1,218.00 / $3,045.00
| Professional | | $852.60 | $1,218.00 | $3,045.00 |