- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,762.72 / $3,881.90 / $8,074.63
| Facility | | $1,762.72 | $3,881.90 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,649.80 / $1,835.83 / $2,904.37
| Professional | | $1,649.80 | $1,835.83 | $2,904.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,105.25 / $16,184.00 / $28,850.83
| Facility | | $8,105.25 | $16,184.00 | $28,850.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.00 / $2,344.98 / $3,755.04
| Professional | | $1,847.00 | $2,344.98 | $3,755.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,145.77 / $2,145.77 / $3,001.27
| Facility | | $2,145.77 | $2,145.77 | $3,001.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.90 / $2,752.96 / $4,399.92
| Professional | | $1,884.90 | $2,752.96 | $4,399.92 |
- 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
- $1,780.67 / $2,501.67 / $4,504.01
| Professional | | $1,780.67 | $2,501.67 | $4,504.01 |