- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,630.78 / $7,585.78
| Facility | | $2,511.89 | $3,630.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $2,454.71
| Professional | | $1,380.38 | $1,862.09 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,168.69 / $6,760.83
| Facility | | $3,090.30 | $4,168.69 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $3,090.30
| Professional | | $794.33 | $1,096.48 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,818.38 / $10,000.00
| Facility | | $1,621.81 | $2,818.38 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,677.35 / $5,495.41
| Professional | | $3,388.44 | $4,677.35 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,621.81 / $4,365.16
| Professional | | $1,202.26 | $1,621.81 | $4,365.16 |