- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $15,848.93
| Facility | | $5,754.40 | $5,754.40 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $1,995.26
| Professional | | $1,230.27 | $1,698.24 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,365.16 / $13,182.57
| Facility | | $3,890.45 | $4,365.16 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,479.11 / $2,137.96
| Professional | | $794.33 | $1,479.11 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,079.46 / $10,000.00
| Facility | | $3,715.35 | $7,079.46 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $4,365.16
| Professional | | $2,290.87 | $2,290.87 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $2,398.83
| Professional | | $1,380.38 | $1,380.38 | $2,398.83 |