- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,701.35 / $3,738.41 / $10,633.40
| Facility | | $1,701.35 | $3,738.41 | $10,633.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.33 / $1,063.33 / $1,230.44
| Professional | | $1,063.33 | $1,063.33 | $1,230.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,498.85 / $2,776.84 / $5,924.33
| Facility | | $2,498.85 | $2,776.84 | $5,924.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.62 / $987.38 / $987.39
| Professional | | $607.62 | $987.38 | $987.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,742.97 / $5,553.04 / $6,663.90
| Facility | | $2,742.97 | $5,553.04 | $6,663.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.06 / $2,061.67 / $4,688.58
| Professional | | $1,519.06 | $2,061.67 | $4,688.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.01 / $911.44 / $1,519.06
| Professional | | $638.01 | $911.44 | $1,519.06 |
- 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 |