- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.11 / $4,433.00 / $8,074.63
| Facility | | $2,290.11 | $4,433.00 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.28 / $2,647.56 / $3,533.43
| Professional | | $2,233.28 | $2,647.56 | $3,533.43 |
- 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
- $2,043.61 / $2,706.12 / $4,406.47
| Professional | | $2,043.61 | $2,706.12 | $4,406.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,639.09 / $2,639.09 / $5,435.84
| Facility | | $2,639.09 | $2,639.09 | $5,435.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.89 / $3,242.00 / $5,153.87
| Professional | | $1,959.89 | $3,242.00 | $5,153.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,403.00 / $3,325.00 / $8,152.00
| Facility | | $1,403.00 | $3,325.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,889.55 / $2,939.50 / $5,611.51
| Professional | | $1,889.55 | $2,939.50 | $5,611.51 |