- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,043.72 / $2,277.29 / $13,845.90
| Facility | | $2,043.72 | $2,277.29 | $13,845.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,277.29 / $2,277.29 / $2,335.67
| Professional | | $2,277.29 | $2,277.29 | $2,335.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $3,992.55
| Professional | | $2,919.60 | $2,919.60 | $3,992.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,306.08 / $7,192.43 / $16,646.98
| Facility | | $5,306.08 | $7,192.43 | $16,646.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,277.29 / $2,919.60 / $3,689.21
| Facility | | $2,277.29 | $2,919.60 | $3,689.21 |
- 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
- $1,226.23 / $1,665.28 / $2,658.62
| Professional | | $1,226.23 | $1,665.28 | $2,658.62 |