- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.57 / $3,908.86 / $7,940.20
| Facility | | $1,897.57 | $3,908.86 | $7,940.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.65 / $2,082.77 / $2,995.70
| Professional | | $1,761.65 | $2,082.77 | $2,995.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,671.00 / $7,198.00 / $12,695.35
| Facility | | $3,671.00 | $7,198.00 | $12,695.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.35 / $2,341.83 / $4,023.83
| Professional | | $1,730.35 | $2,341.83 | $4,023.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $785.00 / $2,256.13
| Facility | | $680.00 | $785.00 | $2,256.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,739.70 / $2,653.79 / $4,592.84
| Professional | | $1,739.70 | $2,653.79 | $4,592.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $781.00 / $2,697.00 / $6,819.50
| Facility | | $781.00 | $2,697.00 | $6,819.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.49 / $2,355.96 / $4,281.38
| Professional | | $1,742.49 | $2,355.96 | $4,281.38 |