- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,189.20 / $5,159.00 / $13,965.00
| Facility | | $3,189.20 | $5,159.00 | $13,965.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,793.73 / $1,793.73 / $2,975.00
| Professional | | $1,793.73 | $1,793.73 | $2,975.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,816.34 / $6,897.93 / $10,927.28
| Facility | | $1,816.34 | $6,897.93 | $10,927.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,296.53 / $3,340.40 / $16,180.06
| Professional | | $2,296.53 | $3,340.40 | $16,180.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,337.96 / $5,687.50 / $10,237.50
| Facility | | $2,337.96 | $5,687.50 | $10,237.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,345.00 / $3,500.00 / $6,443.25
| Facility | | $2,345.00 | $3,500.00 | $6,443.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.00 / $1,470.00 / $17,430.00
| Professional | | $1,470.00 | $1,470.00 | $17,430.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.00 / $1,470.00 / $2,100.00
| Professional | | $1,470.00 | $1,470.00 | $2,100.00 |