- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,888.44 / $16,595.87
| Facility | | $3,801.89 | $5,888.44 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,388.44 / $3,890.45
| Professional | | $2,454.71 | $3,388.44 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,630.27
| Facility | | $870.96 | $1,445.44 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,981.07 / $6,025.60
| Facility | | $2,754.23 | $3,981.07 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $6,760.83 / $10,000.00
| Facility | | $1,698.24 | $6,760.83 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,168.69 / $7,244.36
| Professional | | $3,090.30 | $4,168.69 | $7,244.36 |