- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,180.85 / $4,171.70 / $8,074.63
| Facility | | $2,180.85 | $4,171.70 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,893.50 / $2,327.96 / $3,267.78
| Professional | | $1,893.50 | $2,327.96 | $3,267.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,989.00 / $9,992.00 / $17,206.00
| Facility | | $4,989.00 | $9,992.00 | $17,206.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.57 / $2,731.29 / $4,307.41
| Professional | | $2,004.57 | $2,731.29 | $4,307.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,316.00 / $2,316.00 / $5,203.44
| Facility | | $2,316.00 | $2,316.00 | $5,203.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.39 / $3,061.50 / $4,950.60
| Professional | | $2,266.39 | $3,061.50 | $4,950.60 |
- 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
- $2,065.12 / $2,936.06 / $4,916.72
| Professional | | $2,065.12 | $2,936.06 | $4,916.72 |