- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,720.04 / $3,889.50 / $8,074.63
| Facility | | $1,720.04 | $3,889.50 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.64 / $2,005.49 / $2,975.27
| Professional | | $1,648.64 | $2,005.49 | $2,975.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,299.00 / $11,827.46 / $23,587.93
| Facility | | $5,299.00 | $11,827.46 | $23,587.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.33 / $2,362.52 / $3,519.29
| Professional | | $1,748.33 | $2,362.52 | $3,519.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,003.58 / $2,003.58 / $2,756.77
| Facility | | $2,003.58 | $2,003.58 | $2,756.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.57 / $2,640.61 / $4,197.68
| Professional | | $1,775.57 | $2,640.61 | $4,197.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,403.00 / $3,325.00 / $8,198.00
| Facility | | $1,403.00 | $3,325.00 | $8,198.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,759.01 / $2,427.42 / $4,160.96
| Professional | | $1,759.01 | $2,427.42 | $4,160.96 |