- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,963.86 / $3,980.20 / $8,074.63
| Facility | | $1,963.86 | $3,980.20 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.96 / $2,182.96 / $3,570.72
| Professional | | $1,870.96 | $2,182.96 | $3,570.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,329.50 / $16,401.00 / $29,216.95
| Facility | | $8,329.50 | $16,401.00 | $29,216.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.19 / $2,847.39 / $4,209.81
| Professional | | $1,963.19 | $2,847.39 | $4,209.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.06 / $2,400.06 / $3,358.81
| Facility | | $2,400.06 | $2,400.06 | $3,358.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.28 / $3,017.47 / $4,767.29
| Professional | | $2,065.28 | $3,017.47 | $4,767.29 |
- 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
- $2,060.27 / $2,770.62 / $5,043.52
| Professional | | $2,060.27 | $2,770.62 | $5,043.52 |