- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,608.68 / $1,608.68 / $1,608.68
| Facility | | $1,608.68 | $1,608.68 | $1,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.84 / $7,001.33 / $7,852.66
| Professional | | $1,728.84 | $7,001.33 | $7,852.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,224.00 / $4,490.00 / $14,717.03
| Facility | | $2,224.00 | $4,490.00 | $14,717.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.69 / $1,626.81 / $2,562.50
| Professional | | $1,294.69 | $1,626.81 | $2,562.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.35 / $3,807.68 / $6,241.58
| Professional | | $1,549.35 | $3,807.68 | $6,241.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,129.28 / $1,913.00 / $5,187.00
| Facility | | $1,129.28 | $1,913.00 | $5,187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.83 / $1,888.68 / $10,836.20
| Professional | | $1,316.83 | $1,888.68 | $10,836.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,250.00 / $1,250.00 / $1,250.00
| Facility | | $1,250.00 | $1,250.00 | $1,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.25 / $1,746.23 / $2,883.43
| Professional | | $1,260.25 | $1,746.23 | $2,883.43 |