- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,959.20 / $4,668.50 / $9,767.50
| Facility | | $1,959.20 | $4,668.50 | $9,767.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.07 / $2,063.53 / $3,513.79
| Professional | | $1,697.07 | $2,063.53 | $3,513.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,790.00 / $16,796.00 / $39,007.80
| Facility | | $7,790.00 | $16,796.00 | $39,007.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.53 / $2,475.11 / $4,105.47
| Professional | | $1,901.53 | $2,475.11 | $4,105.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.00 / $950.00 / $2,368.37
| Facility | | $895.00 | $950.00 | $2,368.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.85 / $2,902.81 / $4,550.97
| Professional | | $2,001.85 | $2,902.81 | $4,550.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $8,220.00 / $14,242.22
| Facility | | $3,028.00 | $8,220.00 | $14,242.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.59 / $2,620.56 / $4,468.43
| Professional | | $1,832.59 | $2,620.56 | $4,468.43 |