- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,856.50 / $4,430.50 / $9,248.34
| Facility | | $1,856.50 | $4,430.50 | $9,248.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.41 / $1,925.40 / $2,830.45
| Professional | | $1,607.41 | $1,925.40 | $2,830.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,877.00 / $7,264.00 / $12,274.00
| Facility | | $3,877.00 | $7,264.00 | $12,274.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,643.35 / $2,292.56 / $3,401.29
| Professional | | $1,643.35 | $2,292.56 | $3,401.29 |
- 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
- $1,746.41 / $2,493.55 / $3,780.81
| Professional | | $1,746.41 | $2,493.55 | $3,780.81 |
- 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
- $1,717.81 / $2,438.25 / $3,815.70
| Professional | | $1,717.81 | $2,438.25 | $3,815.70 |