- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,070.92 / $3,622.23 / $7,530.63
| Facility | | $2,070.92 | $3,622.23 | $7,530.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.15 / $2,033.27 / $2,359.60
| Professional | | $1,757.15 | $2,033.27 | $2,359.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,322.82 / $2,723.51 / $7,589.12
| Facility | | $2,322.82 | $2,723.51 | $7,589.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,500.00 / $2,333.30
| Professional | | $1,275.00 | $1,500.00 | $2,333.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,311.21 / $4,225.94 / $7,382.16
| Facility | | $2,311.21 | $4,225.94 | $7,382.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,913.24 / $3,057.46 / $3,663.18
| Professional | | $2,913.24 | $3,057.46 | $3,663.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,649.66 / $2,649.66 / $3,346.94
| Facility | | $2,649.66 | $2,649.66 | $3,346.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,506.13 / $3,346.94
| Professional | | $1,054.29 | $1,506.13 | $3,346.94 |