- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,705.68 / $3,772.57 / $8,373.50
| Facility | | $1,705.68 | $3,772.57 | $8,373.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,594.43 / $1,848.39 / $2,198.44
| Professional | | $1,594.43 | $1,848.39 | $2,198.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.00 / $9,458.00 / $17,400.00
| Facility | | $5,470.00 | $9,458.00 | $17,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,838.42 / $2,220.92 / $2,999.61
| Professional | | $1,838.42 | $2,220.92 | $2,999.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,859.50 / $1,859.50 / $4,919.77
| Facility | | $1,859.50 | $1,859.50 | $4,919.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.81 / $2,463.16 / $4,044.52
| Professional | | $1,659.81 | $2,463.16 | $4,044.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.00 / $3,309.00 / $7,376.50
| Facility | | $1,342.00 | $3,309.00 | $7,376.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.43 / $2,418.59 / $4,313.56
| Professional | | $1,575.43 | $2,418.59 | $4,313.56 |