- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,313.49 / $5,093.50 / $11,137.50
| Facility | | $1,313.49 | $5,093.50 | $11,137.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.96 / $1,188.32 / $1,327.65
| Professional | | $958.96 | $1,188.32 | $1,327.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.00 / $8,007.00 / $17,206.00
| Facility | | $5,470.00 | $8,007.00 | $17,206.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.82 / $4,473.29 / $5,197.10
| Professional | | $1,216.82 | $4,473.29 | $5,197.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,944.29 / $3,944.29 / $4,724.88
| Facility | | $3,944.29 | $3,944.29 | $4,724.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.05 / $2,182.73 / $2,298.34
| Professional | | $1,790.05 | $2,182.73 | $2,298.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,878.00 / $6,351.00 / $11,977.35
| Facility | | $2,878.00 | $6,351.00 | $11,977.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.28 / $1,881.74 / $2,876.76
| Professional | | $1,212.28 | $1,881.74 | $2,876.76 |