- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,351.00 / $4,314.00 / $5,962.00
| Facility | | $2,351.00 | $4,314.00 | $5,962.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,070.77 / $2,419.86 / $3,712.13
| Facility | | $2,070.77 | $2,419.86 | $3,712.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,562.18 / $2,028.84 / $2,305.50
| Professional | | $1,562.18 | $2,028.84 | $2,305.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,522.95 / $5,522.95 / $5,522.95
| Facility | | $5,522.95 | $5,522.95 | $5,522.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.08 / $5,903.12 / $5,903.12
| Professional | | $768.08 | $5,903.12 | $5,903.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,780.15 / $2,178.07 / $2,413.92
| Professional | | $1,780.15 | $2,178.07 | $2,413.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,691.16 / $5,522.95 / $5,522.95
| Facility | | $3,691.16 | $5,522.95 | $5,522.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,334.86 / $5,903.12 / $5,903.12
| Professional | | $3,334.86 | $5,903.12 | $5,903.12 |