- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $10,964.78 / $22,908.68
| Facility | | $4,786.30 | $10,964.78 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,311.31
| Professional | | $2,454.71 | $2,454.71 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $7,762.47 / $22,387.21
| Facility | | $707.95 | $7,762.47 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $2,511.89 / $10,000.00
| Professional | | $831.76 | $2,511.89 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,128.61 / $12,589.25
| Facility | | $2,951.21 | $5,128.61 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $2,290.87 / $5,623.41
| Professional | | $426.58 | $2,290.87 | $5,623.41 |