- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,314.50 / $4,230.50 / $7,940.20
| Facility | | $2,314.50 | $4,230.50 | $7,940.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.19 / $2,623.79 / $4,050.20
| Professional | | $2,215.19 | $2,623.79 | $4,050.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,486.55 / $7,367.56 / $12,695.35
| Facility | | $3,486.55 | $7,367.56 | $12,695.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.98 / $2,956.54 / $5,055.18
| Professional | | $2,293.98 | $2,956.54 | $5,055.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $785.00 / $2,847.56
| Facility | | $680.00 | $785.00 | $2,847.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,300.35 / $3,377.90 / $5,846.49
| Professional | | $2,300.35 | $3,377.90 | $5,846.49 |
- 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
- $2,211.29 / $3,047.31 / $5,444.29
| Professional | | $2,211.29 | $3,047.31 | $5,444.29 |