- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,060.17 / $2,060.17 / $11,009.00
| Facility | | $2,060.17 | $2,060.17 | $11,009.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.38 / $2,060.17 / $2,060.17
| Professional | | $1,554.38 | $2,060.17 | $2,060.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,540.35 / $26,444.67 / $45,003.43
| Facility | | $15,540.35 | $26,444.67 | $45,003.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,779.22 / $3,481.70 / $4,855.89
| Facility | | $2,779.22 | $3,481.70 | $4,855.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,449.82 / $4,111.35 / $8,125.37
| Professional | | $2,449.82 | $4,111.35 | $8,125.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,638.27 / $4,467.08 / $7,967.49
| Professional | | $2,638.27 | $4,467.08 | $7,967.49 |