- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $11,220.18 / $18,197.01
| Facility | | $2,344.23 | $11,220.18 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,238.72 / $5,128.61
| Professional | | $1,995.26 | $2,238.72 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $3,890.45
| Facility | | $1,698.24 | $2,691.53 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $4,365.16
| Professional | | $1,698.24 | $2,511.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $8,709.64 / $12,022.64
| Professional | | $6,165.95 | $8,709.64 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $4,365.16
| Facility | | $1,995.26 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $10,000.00 / $12,882.50
| Professional | | $1,737.80 | $10,000.00 | $12,882.50 |