- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,764.63 / $3,889.50 / $8,074.63
| Facility | | $1,764.63 | $3,889.50 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,699.64 / $1,973.63 / $3,135.32
| Professional | | $1,699.64 | $1,973.63 | $3,135.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,105.25 / $16,184.00 / $28,925.33
| Facility | | $8,105.25 | $16,184.00 | $28,925.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.69 / $2,420.50 / $3,806.15
| Professional | | $1,863.69 | $2,420.50 | $3,806.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,176.71 / $2,176.71 / $3,040.70
| Facility | | $2,176.71 | $2,176.71 | $3,040.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.05 / $2,750.63 / $4,450.78
| Professional | | $1,918.05 | $2,750.63 | $4,450.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,403.00 / $3,325.00 / $8,198.00
| Facility | | $1,403.00 | $3,325.00 | $8,198.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,909.52 / $2,566.14 / $4,570.30
| Professional | | $1,909.52 | $2,566.14 | $4,570.30 |