- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,228.17 / $4,184.56 / $8,074.63
| Facility | | $2,228.17 | $4,184.56 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.66 / $2,487.75 / $3,361.73
| Professional | | $2,170.66 | $2,487.75 | $3,361.73 |
- 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
- $2,030.87 / $2,732.21 / $4,414.95
| Professional | | $2,030.87 | $2,732.21 | $4,414.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,357.76 / $2,357.76 / $5,217.64
| Facility | | $2,357.76 | $2,357.76 | $5,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,285.55 / $3,121.61 / $5,210.75
| Professional | | $2,285.55 | $3,121.61 | $5,210.75 |
- 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
- $2,106.86 / $2,981.61 / $5,263.73
| Professional | | $2,106.86 | $2,981.61 | $5,263.73 |