- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,559.95 / $4,230.50 / $7,975.63
| Facility | | $2,559.95 | $4,230.50 | $7,975.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,531.12 / $2,874.20 / $4,265.58
| Professional | | $2,531.12 | $2,874.20 | $4,265.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,838.00 / $10,908.00 / $22,593.00
| Facility | | $4,838.00 | $10,908.00 | $22,593.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,538.48 / $3,229.86 / $5,583.92
| Professional | | $2,538.48 | $3,229.86 | $5,583.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $870.49 / $3,064.82
| Facility | | $680.00 | $870.49 | $3,064.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,435.01 / $3,647.65 / $6,489.57
| Professional | | $2,435.01 | $3,647.65 | $6,489.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $718.00 / $2,575.00 / $7,326.50
| Facility | | $718.00 | $2,575.00 | $7,326.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,441.83 / $3,474.02 / $6,064.82
| Professional | | $2,441.83 | $3,474.02 | $6,064.82 |