- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,113.76 / $4,668.50 / $9,767.50
| Facility | | $2,113.76 | $4,668.50 | $9,767.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.28 / $2,255.75 / $3,432.09
| Professional | | $1,905.28 | $2,255.75 | $3,432.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,701.50 / $16,796.00 / $48,414.52
| Facility | | $7,701.50 | $16,796.00 | $48,414.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.53 / $2,705.81 / $4,473.51
| Professional | | $1,836.53 | $2,705.81 | $4,473.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.00 / $950.00 / $2,586.94
| Facility | | $895.00 | $950.00 | $2,586.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.12 / $3,049.18 / $4,794.22
| Professional | | $2,116.12 | $3,049.18 | $4,794.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $7,457.00 / $14,139.00
| Facility | | $3,028.00 | $7,457.00 | $14,139.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,886.90 / $2,712.63 / $4,728.39
| Professional | | $1,886.90 | $2,712.63 | $4,728.39 |