- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,628.27 / $13,772.10 / $18,056.20
| Facility | | $2,628.27 | $13,772.10 | $18,056.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,628.27 / $2,628.27 / $2,628.27
| Professional | | $2,628.27 | $2,628.27 | $2,628.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,205.31 / $3,296.67 / $10,332.56
| Facility | | $3,205.31 | $3,296.67 | $10,332.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.11 / $4,026.64 / $6,860.83
| Professional | | $1,723.11 | $4,026.64 | $6,860.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,750.00 / $4,312.50 / $15,187.50
| Facility | | $3,750.00 | $4,312.50 | $15,187.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,043.65 / $3,789.40 / $4,494.72
| Professional | | $3,043.65 | $3,789.40 | $4,494.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.53 / $1,575.00 / $2,250.00
| Professional | | $1,226.53 | $1,575.00 | $2,250.00 |