- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $12,022.64 / $16,595.87
| Facility | | $4,897.79 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $7,762.47
| Professional | | $1,548.82 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Professional | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,511.89 / $10,964.78
| Facility | | $1,862.09 | $2,511.89 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,370.32 / $10,964.78
| Professional | | $4,168.69 | $5,370.32 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $10,232.93
| Professional | | $7,079.46 | $7,079.46 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,762.47 / $11,220.18
| Facility | | $2,454.71 | $7,762.47 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,659.59 / $5,495.41
| Professional | | $60.26 | $1,659.59 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,466.84 / $10,000.00
| Professional | | $4,365.16 | $4,466.84 | $10,000.00 |