- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,740.87 / $3,940.00 / $7,602.00
| Facility | | $1,740.87 | $3,940.00 | $7,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.60 / $1,740.87 / $1,830.33
| Professional | | $1,218.60 | $1,740.87 | $1,830.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.00 / $4,002.00 / $6,243.00
| Facility | | $2,225.00 | $4,002.00 | $6,243.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.27 / $2,374.08 / $3,999.30
| Professional | | $1,729.27 | $2,374.08 | $3,999.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,206.88 / $5,147.92 / $5,298.80
| Facility | | $4,206.88 | $5,147.92 | $5,298.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,018.38 / $7,018.38 / $7,018.38
| Professional | | $7,018.38 | $7,018.38 | $7,018.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,695.00 / $3,616.00 / $6,285.00
| Facility | | $1,695.00 | $3,616.00 | $6,285.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.99 / $2,510.48 / $3,806.94
| Professional | | $1,707.99 | $2,510.48 | $3,806.94 |