- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,167.65 / $3,949.50 / $7,879.32
| Facility | | $2,167.65 | $3,949.50 | $7,879.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,998.82 / $2,341.90 / $3,525.90
| Professional | | $1,998.82 | $2,341.90 | $3,525.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,671.00 / $9,122.94 / $14,433.40
| Facility | | $3,671.00 | $9,122.94 | $14,433.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.05 / $2,967.09 / $4,502.72
| Professional | | $2,090.05 | $2,967.09 | $4,502.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $870.49 / $2,540.38
| Facility | | $680.00 | $870.49 | $2,540.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,114.73 / $3,093.37 / $5,265.24
| Professional | | $2,114.73 | $3,093.37 | $5,265.24 |
- 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
- $2,028.09 / $2,748.64 / $4,906.75
| Professional | | $2,028.09 | $2,748.64 | $4,906.75 |