- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,877.50 / $4,889.50 / $8,952.52
| Facility | | $2,877.50 | $4,889.50 | $8,952.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,184.13 / $4,898.93 / $7,680.73
| Professional | | $4,184.13 | $4,898.93 | $7,680.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,302.10 / $7,264.00 / $11,253.00
| Facility | | $3,302.10 | $7,264.00 | $11,253.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,324.38 / $5,603.06 / $9,348.89
| Professional | | $4,324.38 | $5,603.06 | $9,348.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $870.49 / $5,349.05
| Facility | | $680.00 | $870.49 | $5,349.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,474.63 / $6,463.04 / $11,038.35
| Professional | | $4,474.63 | $6,463.04 | $11,038.35 |
- 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
- $4,292.14 / $5,838.12 / $10,691.95
| Professional | | $4,292.14 | $5,838.12 | $10,691.95 |