- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,577.40 / $3,920.00 / $8,945.83
| Facility | | $2,577.40 | $3,920.00 | $8,945.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.60 / $2,577.40 / $2,744.00
| Professional | | $2,077.60 | $2,577.40 | $2,744.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.36 / $4,751.43 / $9,702.00
| Facility | | $385.36 | $4,751.43 | $9,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.90 / $3,850.96 / $9,383.69
| Professional | | $1,830.90 | $3,850.96 | $9,383.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,548.00 / $9,954.40 / $20,605.61
| Facility | | $2,548.00 | $9,954.40 | $20,605.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,744.00 / $6,164.20 / $9,682.40
| Professional | | $2,744.00 | $6,164.20 | $9,682.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.40 / $2,352.00 / $6,879.21
| Professional | | $1,651.40 | $2,352.00 | $6,879.21 |