- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.84 / $3,938.83 / $8,340.00
| Facility | | $1,794.84 | $3,938.83 | $8,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,684.78 / $1,990.85 / $2,713.51
| Professional | | $1,684.78 | $1,990.85 | $2,713.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,769.10 / $8,883.46 / $15,216.00
| Facility | | $4,769.10 | $8,883.46 | $15,216.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.15 / $2,201.52 / $3,195.13
| Professional | | $1,623.15 | $2,201.52 | $3,195.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,899.91 / $1,899.91 / $4,907.15
| Facility | | $1,899.91 | $1,899.91 | $4,907.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.62 / $2,549.09 / $4,209.05
| Professional | | $1,755.62 | $2,549.09 | $4,209.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,283.50 / $3,324.00 / $7,965.00
| Facility | | $1,283.50 | $3,324.00 | $7,965.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.65 / $2,468.23 / $4,379.49
| Professional | | $1,798.65 | $2,468.23 | $4,379.49 |