- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,127.64 / $2,127.64 / $2,127.64
| Facility | | $2,127.64 | $2,127.64 | $2,127.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.72 / $2,127.64 / $2,872.31
| Professional | | $1,227.72 | $2,127.64 | $2,872.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,931.69 / $9,625.46 / $12,949.34
| Facility | | $7,931.69 | $9,625.46 | $12,949.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.35 / $1,345.69 / $1,587.91
| Professional | | $982.35 | $1,345.69 | $1,587.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,668.00 / $14,352.00 / $15,143.00
| Facility | | $13,668.00 | $14,352.00 | $15,143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.97 / $1,657.20 / $4,603.30
| Professional | | $1,019.97 | $1,657.20 | $4,603.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.00 / $4,852.00 / $9,624.00
| Facility | | $1,404.00 | $4,852.00 | $9,624.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.15 / $1,309.75 / $2,125.98
| Professional | | $953.15 | $1,309.75 | $2,125.98 |