- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,585.60 / $4,328.50 / $7,940.20
| Facility | | $2,585.60 | $4,328.50 | $7,940.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,587.13 / $3,033.65 / $4,383.93
| Professional | | $2,587.13 | $3,033.65 | $4,383.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,114.84 / $9,122.94 / $14,433.40
| Facility | | $4,114.84 | $9,122.94 | $14,433.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,669.90 / $3,453.82 / $5,875.77
| Professional | | $2,669.90 | $3,453.82 | $5,875.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $870.49 / $3,293.81
| Facility | | $680.00 | $870.49 | $3,293.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,728.12 / $4,008.30 / $6,799.19
| Professional | | $2,728.12 | $4,008.30 | $6,799.19 |
- 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
- $2,601.65 / $3,614.06 / $6,610.32
| Professional | | $2,601.65 | $3,614.06 | $6,610.32 |