- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,757.15 / $1,957.96 / $11,904.40
| Facility | | $1,757.15 | $1,957.96 | $11,904.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,957.96 / $1,957.96 / $2,008.17
| Professional | | $1,957.96 | $1,957.96 | $2,008.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,635.72 / $3,464.09
| Professional | | $2,510.21 | $2,635.72 | $3,464.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,562.07 / $6,183.92 / $14,312.75
| Facility | | $4,562.07 | $6,183.92 | $14,312.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,957.96 / $2,510.21 / $3,171.90
| Facility | | $1,957.96 | $2,510.21 | $3,171.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $1,500.00 / $1,500.00
| Professional | | $1,500.00 | $1,500.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,255.10 / $2,285.82
| Professional | | $1,054.29 | $1,255.10 | $2,285.82 |