- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,623.63 / $4,296.60
| Facility | | $1,277.00 | $2,623.63 | $4,296.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,141.91 / $2,844.45 / $3,143.92
| Professional | | $2,141.91 | $2,844.45 | $3,143.92 |
- 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
- $2,544.62 / $3,180.78 / $3,367.88
| Professional | | $2,544.62 | $3,180.78 | $3,367.88 |
- 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
- $2,548.80 / $3,531.82 / $4,457.17
| Professional | | $2,548.80 | $3,531.82 | $4,457.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,667.00 / $6,957.00
| Facility | | $1,565.00 | $2,667.00 | $6,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.09 / $2,836.46 / $4,536.26
| Professional | | $2,119.09 | $2,836.46 | $4,536.26 |