- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,348.66 / $5,512.50 / $10,032.79
| Facility | | $3,348.66 | $5,512.50 | $10,032.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.50 / $2,940.00 / $3,197.25
| Professional | | $2,572.50 | $2,940.00 | $3,197.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,007.84 / $5,393.06 / $16,032.92
| Facility | | $2,007.84 | $5,393.06 | $16,032.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $1,543.50 / $4,132.23
| Professional | | $1,500.00 | $1,543.50 | $4,132.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.69 / $5,700.30 / $11,279.59
| Facility | | $2,626.69 | $5,700.30 | $11,279.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,476.30 / $4,476.30 / $5,363.11
| Professional | | $4,476.30 | $4,476.30 | $5,363.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $2,205.00 / $4,156.43
| Professional | | $1,543.50 | $2,205.00 | $4,156.43 |