- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,787.42 / $4,597.00 / $9,795.50
| Facility | | $1,787.42 | $4,597.00 | $9,795.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,432.09 / $1,708.30 / $2,506.30
| Professional | | $1,432.09 | $1,708.30 | $2,506.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,242.00 / $5,379.00 / $11,936.00
| Facility | | $3,242.00 | $5,379.00 | $11,936.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.61 / $2,043.41 / $2,971.59
| Professional | | $1,426.61 | $2,043.41 | $2,971.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,685.16 / $3,685.16 / $3,909.74
| Facility | | $3,685.16 | $3,685.16 | $3,909.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.75 / $2,176.44 / $3,370.81
| Professional | | $1,515.75 | $2,176.44 | $3,370.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,059.00 / $6,516.50 / $12,055.49
| Facility | | $3,059.00 | $6,516.50 | $12,055.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.85 / $2,102.08 / $3,449.47
| Professional | | $1,498.85 | $2,102.08 | $3,449.47 |