- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,203.69 / $11,547.40 / $15,139.40
| Facility | | $2,203.69 | $11,547.40 | $15,139.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,203.69 / $2,203.69 / $2,203.69
| Professional | | $2,203.69 | $2,203.69 | $2,203.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,092.90 / $2,152.55 / $6,746.62
| Facility | | $2,092.90 | $2,152.55 | $6,746.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.06 / $2,537.58 / $4,480.03
| Professional | | $1,125.06 | $2,537.58 | $4,480.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.56 / $2,815.84 / $9,916.67
| Facility | | $2,448.56 | $2,815.84 | $9,916.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,448.56 / $2,641.54 / $2,935.04
| Professional | | $2,448.56 | $2,641.54 | $2,935.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,028.40 / $1,469.14
| Professional | | $1,028.40 | $1,028.40 | $1,469.14 |