- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,969.52 / $4,010.61 / $9,520.58
| Facility | | $2,969.52 | $4,010.61 | $9,520.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.21 / $3,579.01 / $6,893.03
| Professional | | $2,589.21 | $3,579.01 | $6,893.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,310.00 / $5,157.10 / $12,815.65
| Facility | | $1,310.00 | $5,157.10 | $12,815.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.00 / $1,059.18 / $1,645.25
| Professional | | $930.00 | $1,059.18 | $1,645.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,636.75 / $14,397.00 / $29,304.50
| Facility | | $6,636.75 | $14,397.00 | $29,304.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,821.49 / $2,821.49 / $2,821.49
| Professional | | $2,821.49 | $2,821.49 | $2,821.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $7,228.00 / $12,726.00
| Facility | | $2,912.00 | $7,228.00 | $12,726.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.17 / $2,986.18 / $5,458.66
| Professional | | $862.17 | $2,986.18 | $5,458.66 |