- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,883.61 / $6,336.21 / $18,022.50
| Facility | | $2,883.61 | $6,336.21 | $18,022.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.26 / $1,802.26 / $2,085.46
| Professional | | $1,802.26 | $1,802.26 | $2,085.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,235.30 / $4,706.46 / $10,041.14
| Facility | | $4,235.30 | $4,706.46 | $10,041.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.85 / $1,673.52 / $2,426.60
| Professional | | $1,029.85 | $1,673.52 | $2,426.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,649.04 / $9,412.27 / $11,294.59
| Facility | | $4,649.04 | $9,412.27 | $11,294.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.65 / $3,494.32 / $7,946.66
| Professional | | $2,574.65 | $3,494.32 | $7,946.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $1,544.79 / $1,544.79
| Professional | | $1,081.34 | $1,544.79 | $1,544.79 |
- 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 |