- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,673.04 / $4,188.50 / $8,828.00
| Facility | | $1,673.04 | $4,188.50 | $8,828.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,483.69 / $1,631.55 / $2,591.90
| Professional | | $1,483.69 | $1,631.55 | $2,591.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,068.50 / $10,923.00 / $22,453.48
| Facility | | $5,068.50 | $10,923.00 | $22,453.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.75 / $1,948.02 / $3,186.21
| Professional | | $1,513.75 | $1,948.02 | $3,186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.00 / $950.00 / $1,815.11
| Facility | | $895.00 | $950.00 | $1,815.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.06 / $2,309.15 / $3,694.74
| Professional | | $1,628.06 | $2,309.15 | $3,694.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $6,231.00 / $11,869.99
| Facility | | $2,912.00 | $6,231.00 | $11,869.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.58 / $2,048.33 / $3,586.81
| Professional | | $1,453.58 | $2,048.33 | $3,586.81 |