- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,843.90 / $3,889.50 / $8,074.63
| Facility | | $1,843.90 | $3,889.50 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,838.57 / $2,102.75 / $3,276.49
| Professional | | $1,838.57 | $2,102.75 | $3,276.49 |
- 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
- $1,942.60 / $2,507.39 / $4,184.58
| Professional | | $1,942.60 | $2,507.39 | $4,184.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,356.59 / $2,356.59 / $3,323.58
| Facility | | $2,356.59 | $2,356.59 | $3,323.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,923.60 / $2,852.87 / $4,607.49
| Professional | | $1,923.60 | $2,852.87 | $4,607.49 |
- 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
- $1,862.20 / $2,691.38 / $4,745.91
| Professional | | $1,862.20 | $2,691.38 | $4,745.91 |