- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.48 / $2,204.78 / $2,585.10
| Facility | | $1,850.48 | $2,204.78 | $2,585.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.40 / $1,850.48 / $2,456.21
| Professional | | $1,260.40 | $1,850.48 | $2,456.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,430.62 / $5,430.62 / $6,516.74
| Facility | | $5,430.62 | $5,430.62 | $6,516.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.75 / $1,828.79 / $2,237.58
| Professional | | $1,381.75 | $1,828.79 | $2,237.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,337.37 / $4,337.37 / $4,337.37
| Facility | | $4,337.37 | $4,337.37 | $4,337.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.00 / $2,502.32 / $3,099.71
| Professional | | $1,751.00 | $2,502.32 | $3,099.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,828.00 / $6,957.00
| Facility | | $1,565.00 | $2,828.00 | $6,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.76 / $1,988.27 / $3,159.98
| Professional | | $1,541.76 | $1,988.27 | $3,159.98 |