- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,570.61 / $3,726.77 / $8,074.63
| Facility | | $1,570.61 | $3,726.77 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.67 / $1,629.28 / $2,575.28
| Professional | | $1,398.67 | $1,629.28 | $2,575.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,438.50 / $15,492.50 / $27,191.88
| Facility | | $7,438.50 | $15,492.50 | $27,191.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.32 / $2,000.68 / $3,141.60
| Professional | | $1,465.32 | $2,000.68 | $3,141.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,793.00 / $1,793.00 / $2,507.01
| Facility | | $1,793.00 | $1,793.00 | $2,507.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.92 / $2,326.23 / $3,709.60
| Professional | | $1,591.92 | $2,326.23 | $3,709.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,292.00 / $3,325.00 / $8,198.00
| Facility | | $1,292.00 | $3,325.00 | $8,198.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.32 / $2,113.76 / $3,906.16
| Professional | | $1,540.32 | $2,113.76 | $3,906.16 |