- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.19 / $3,949.50 / $7,940.20
| Facility | | $2,202.19 | $3,949.50 | $7,940.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,050.32 / $2,360.44 / $3,524.20
| Professional | | $2,050.32 | $2,360.44 | $3,524.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,769.10 / $10,908.00 / $22,593.00
| Facility | | $4,769.10 | $10,908.00 | $22,593.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,105.46 / $2,713.68 / $4,447.55
| Professional | | $2,105.46 | $2,713.68 | $4,447.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $870.49 / $2,543.44
| Facility | | $680.00 | $870.49 | $2,543.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.98 / $3,155.13 / $5,500.51
| Professional | | $2,150.98 | $3,155.13 | $5,500.51 |
- 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
- $2,037.01 / $2,914.26 / $5,205.00
| Professional | | $2,037.01 | $2,914.26 | $5,205.00 |