- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $21,877.62
| Facility | | $7,943.28 | $7,943.28 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $2,570.40
| Professional | | $478.63 | $478.63 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,025.60 / $18,197.01
| Facility | | $5,495.41 | $6,025.60 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $2,041.74 / $2,951.21
| Professional | | $208.93 | $2,041.74 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $10,000.00 / $13,803.84
| Facility | | $5,128.61 | $10,000.00 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $6,025.60
| Professional | | $3,162.28 | $3,162.28 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $3,311.31
| Professional | | $1,905.46 | $1,905.46 | $3,311.31 |