- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,030.00 / $2,334.50 / $4,060.00
| Facility | | $2,030.00 | $2,334.50 | $4,060.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.40 / $2,334.50 / $2,334.50
| Professional | | $1,583.40 | $2,334.50 | $2,334.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.89 / $652.76 / $878.17
| Facility | | $537.89 | $652.76 | $878.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.43 / $384.32 / $1,317.17
| Professional | | $316.43 | $384.32 | $1,317.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,293.10 / $1,649.38 / $4,393.93
| Facility | | $1,293.10 | $1,649.38 | $4,393.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.44 / $879.19 / $960.21
| Professional | | $141.44 | $879.19 | $960.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.60 / $852.60 / $1,827.00
| Professional | | $852.60 | $852.60 | $1,827.00 |