- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,491.88 / $3,959.50 / $8,353.50
| Facility | | $1,491.88 | $3,959.50 | $8,353.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.72 / $1,617.05 / $2,385.92
| Professional | | $1,411.72 | $1,617.05 | $2,385.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,877.00 / $7,200.00 / $12,274.00
| Facility | | $3,877.00 | $7,200.00 | $12,274.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.93 / $1,866.91 / $2,875.29
| Professional | | $1,390.93 | $1,866.91 | $2,875.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,185.38 / $3,196.83 / $3,449.74
| Facility | | $3,185.38 | $3,196.83 | $3,449.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.62 / $2,110.12 / $3,317.56
| Professional | | $1,451.62 | $2,110.12 | $3,317.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,206.00 / $6,578.00 / $12,241.00
| Facility | | $3,206.00 | $6,578.00 | $12,241.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.31 / $1,988.50 / $3,230.44
| Professional | | $1,412.31 | $1,988.50 | $3,230.44 |