- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.10 / $1,404.10 / $2,525.00
| Facility | | $1,404.10 | $1,404.10 | $2,525.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.17 / $1,404.10 / $1,446.07
| Professional | | $1,233.17 | $1,404.10 | $1,446.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,299.43 / $8,040.40 / $16,508.77
| Facility | | $5,299.43 | $8,040.40 | $16,508.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,055.84 / $2,666.15 / $3,500.00
| Facility | | $2,055.84 | $2,666.15 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,919.12 / $3,468.03 / $5,732.45
| Professional | | $1,919.12 | $3,468.03 | $5,732.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,948.42 / $3,300.22 / $5,620.45
| Professional | | $1,948.42 | $3,300.22 | $5,620.45 |