- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,784.92 / $3,889.50 / $8,072.00
| Facility | | $1,784.92 | $3,889.50 | $8,072.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.75 / $2,370.48 / $3,182.73
| Professional | | $1,443.75 | $2,370.48 | $3,182.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,671.00 / $7,979.00 / $13,400.83
| Facility | | $3,671.00 | $7,979.00 | $13,400.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.75 / $2,078.69 / $2,695.51
| Professional | | $1,133.75 | $2,078.69 | $2,695.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $785.00 / $2,588.77
| Facility | | $680.00 | $785.00 | $2,588.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.90 / $3,436.57 / $6,075.03
| Professional | | $1,853.90 | $3,436.57 | $6,075.03 |
- 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
- $1,815.02 / $2,838.15 / $4,937.03
| Professional | | $1,815.02 | $2,838.15 | $4,937.03 |