- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,855.00 / $2,067.00 / $12,567.40
| Facility | | $1,855.00 | $2,067.00 | $12,567.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,067.00 / $2,067.00 / $2,120.00
| Professional | | $2,067.00 | $2,067.00 | $2,120.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,650.00 / $2,650.00 / $3,623.88
| Professional | | $2,650.00 | $2,650.00 | $3,623.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,816.10 / $6,528.28 / $15,109.77
| Facility | | $4,816.10 | $6,528.28 | $15,109.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,855.00 / $2,650.00 / $3,286.00
| Facility | | $1,855.00 | $2,650.00 | $3,286.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.00 / $1,457.50 / $2,413.12
| Professional | | $1,113.00 | $1,457.50 | $2,413.12 |