- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,012.94 / $4,080.28 / $8,074.63
| Facility | | $2,012.94 | $4,080.28 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,839.64 / $2,211.46 / $2,957.12
| Professional | | $1,839.64 | $2,211.46 | $2,957.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,769.10 / $8,981.00 / $15,216.00
| Facility | | $4,769.10 | $8,981.00 | $15,216.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.75 / $2,496.69 / $3,881.92
| Professional | | $1,854.75 | $2,496.69 | $3,881.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,152.30 / $2,152.30 / $5,078.30
| Facility | | $2,152.30 | $2,152.30 | $5,078.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,094.03 / $2,826.65 / $4,670.49
| Professional | | $2,094.03 | $2,826.65 | $4,670.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,345.00 / $3,265.50 / $6,998.50
| Facility | | $1,345.00 | $3,265.50 | $6,998.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.01 / $2,775.03 / $4,404.14
| Professional | | $1,969.01 | $2,775.03 | $4,404.14 |