- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,028.67 / $5,063.00 / $6,915.00
| Facility | | $2,028.67 | $5,063.00 | $6,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.77 / $2,028.67 / $5,215.10
| Professional | | $1,747.77 | $2,028.67 | $5,215.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,226.13 / $6,105.48 / $13,137.87
| Facility | | $2,226.13 | $6,105.48 | $13,137.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.42 / $2,792.35 / $5,393.82
| Professional | | $1,783.42 | $2,792.35 | $5,393.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.19 / $3,337.97 / $5,250.89
| Professional | | $2,001.19 | $3,337.97 | $5,250.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,109.14 / $2,460.67 / $6,892.74
| Professional | | $2,109.14 | $2,460.67 | $6,892.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.00 / $3,629.00 / $10,000.00
| Facility | | $1,036.00 | $3,629.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.28 / $2,641.51 / $4,753.81
| Professional | | $1,878.28 | $2,641.51 | $4,753.81 |