- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.82 / $4,054.50 / $10,573.50
| Facility | | $2,041.82 | $4,054.50 | $10,573.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,762.25 / $2,199.50 / $2,252.50
| Professional | | $1,762.25 | $2,199.50 | $2,252.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,826.30 / $6,935.76 / $10,987.21
| Facility | | $1,826.30 | $6,935.76 | $10,987.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.80 / $2,529.16 / $12,250.62
| Professional | | $1,738.80 | $2,529.16 | $12,250.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,454.69 / $1,840.27 / $4,840.22
| Facility | | $1,454.69 | $1,840.27 | $4,840.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,775.50 / $2,650.00 / $5,199.64
| Facility | | $1,775.50 | $2,650.00 | $5,199.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.00 / $1,113.00 / $13,197.00
| Professional | | $1,113.00 | $1,113.00 | $13,197.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.00 / $1,113.00 / $1,590.00
| Professional | | $1,113.00 | $1,113.00 | $1,590.00 |