- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $22,387.21
| Facility | | $8,128.31 | $8,128.31 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $2,754.23
| Professional | | $1,737.80 | $2,344.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,165.95 / $18,620.87
| Facility | | $5,495.41 | $6,165.95 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.41 / $2,089.30 / $3,019.95
| Professional | | $7.41 | $2,089.30 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $10,000.00 / $14,125.38
| Facility | | $5,248.07 | $10,000.00 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $6,165.95
| Professional | | $3,235.94 | $3,235.94 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $3,235.94
| Professional | | $1,905.46 | $1,905.46 | $3,235.94 |