- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.00 / $1,583.40 / $9,627.07
| Facility | | $1,421.00 | $1,583.40 | $9,627.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.40 / $1,583.40 / $1,624.00
| Professional | | $1,583.40 | $1,583.40 | $1,624.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,030.00 / $2,131.50 / $2,801.40
| Professional | | $2,030.00 | $2,131.50 | $2,801.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,352.69 / $4,116.84 / $11,574.65
| Facility | | $1,352.69 | $4,116.84 | $11,574.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,563.10 / $2,030.00 / $2,172.10
| Facility | | $1,563.10 | $2,030.00 | $2,172.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,030.00 / $2,030.00 / $2,030.00
| Facility | | $2,030.00 | $2,030.00 | $2,030.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.60 / $1,015.00 / $2,030.00
| Professional | | $852.60 | $1,015.00 | $2,030.00 |