- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,816.38 / $5,848.13 / $7,765.11
| Facility | | $3,816.38 | $5,848.13 | $7,765.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,793.22 / $5,793.22 / $8,622.24
| Professional | | $5,793.22 | $5,793.22 | $8,622.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,567.10 / $3,520.00 / $4,400.00
| Facility | | $1,567.10 | $3,520.00 | $4,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.40 / $2,129.60 / $2,583.67
| Professional | | $1,148.40 | $2,129.60 | $2,583.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,288.00 / $4,118.39 / $12,744.16
| Facility | | $2,288.00 | $4,118.39 | $12,744.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,816.00 / $4,044.92 / $5,056.14
| Professional | | $2,816.00 | $4,044.92 | $5,056.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.00 / $3,520.00 / $3,696.00
| Professional | | $880.00 | $3,520.00 | $3,696.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,280.00 / $5,280.00 / $5,280.00
| Facility | | $5,280.00 | $5,280.00 | $5,280.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.40 / $1,478.40 / $3,520.00
| Professional | | $1,478.40 | $1,478.40 | $3,520.00 |