- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $4,230.50 / $7,940.20
| Facility | | $2,747.00 | $4,230.50 | $7,940.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,650.38 / $3,227.57 / $5,109.70
| Professional | | $2,650.38 | $3,227.57 | $5,109.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,769.10 / $11,780.00 / $23,711.32
| Facility | | $4,769.10 | $11,780.00 | $23,711.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.82 / $3,745.90 / $6,228.89
| Professional | | $2,857.82 | $3,745.90 | $6,228.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $870.49 / $3,539.93
| Facility | | $680.00 | $870.49 | $3,539.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,912.91 / $4,248.54 / $7,202.49
| Professional | | $2,912.91 | $4,248.54 | $7,202.49 |
- 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
- $2,677.93 / $3,783.86 / $6,737.05
| Professional | | $2,677.93 | $3,783.86 | $6,737.05 |