- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $9,120.11 / $16,595.87
| Facility | | $5,623.41 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,786.30 / $7,079.46
| Professional | | $3,715.35 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,890.45 / $5,248.07
| Professional | | $2,238.72 | $3,890.45 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,623.41 / $9,332.54
| Professional | | $1,819.70 | $5,623.41 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,786.30 / $10,000.00
| Facility | | $1,995.26 | $4,786.30 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $6,760.83 / $9,120.11
| Facility | | $2,454.71 | $6,760.83 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $4,265.80 / $9,332.54
| Professional | | $1,949.84 | $4,265.80 | $9,332.54 |