- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,258.59 / $3,780.50 / $7,948.98
| Facility | | $2,258.59 | $3,780.50 | $7,948.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,189.50 / $2,531.23 / $3,950.23
| Professional | | $2,189.50 | $2,531.23 | $3,950.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,512.20 / $16,401.00 / $29,866.68
| Facility | | $8,512.20 | $16,401.00 | $29,866.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,310.53 / $3,083.26 / $5,241.92
| Professional | | $2,310.53 | $3,083.26 | $5,241.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.00 / $1,000.00 / $2,864.64
| Facility | | $900.00 | $1,000.00 | $2,864.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,455.55 / $3,464.51 / $5,538.75
| Professional | | $2,455.55 | $3,464.51 | $5,538.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.00 / $3,269.00 / $7,384.00
| Facility | | $1,185.00 | $3,269.00 | $7,384.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,206.88 / $3,127.16 / $5,493.88
| Professional | | $2,206.88 | $3,127.16 | $5,493.88 |