- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $12,022.64
| Facility | | $5,495.41 | $5,495.41 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $5,370.32
| Professional | | $2,884.03 | $3,801.89 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,120.11 / $14,791.08
| Facility | | $6,760.83 | $9,120.11 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $181.97 / $6,918.31
| Professional | | $109.65 | $181.97 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $8,912.51 / $31,622.78
| Facility | | $3,548.13 | $8,912.51 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $10,000.00 / $11,748.98
| Professional | | $5,754.40 | $10,000.00 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,311.31 / $9,549.93
| Professional | | $2,630.27 | $3,311.31 | $9,549.93 |