- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,083.64 / $6,775.75 / $19,272.80
| Facility | | $3,083.64 | $6,775.75 | $19,272.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.43 / $455.43 / $2,147.54
| Professional | | $455.43 | $455.43 | $2,147.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,529.10 / $5,032.93 / $10,737.68
| Facility | | $4,529.10 | $5,032.93 | $10,737.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.30 / $1,789.61 / $1,789.61
| Professional | | $1,101.30 | $1,789.61 | $1,789.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,971.54 / $10,064.66 / $12,078.08
| Facility | | $4,971.54 | $10,064.66 | $12,078.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,753.25 / $3,996.07 / $9,069.48
| Professional | | $2,753.25 | $3,996.07 | $9,069.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.36 / $1,651.95 / $2,753.25
| Professional | | $1,156.36 | $1,651.95 | $2,753.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |