- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,110.65 / $3,008.50 / $7,325.50
| Facility | | $1,110.65 | $3,008.50 | $7,325.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.90 / $1,121.43 / $1,799.82
| Professional | | $968.90 | $1,121.43 | $1,799.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,877.00 / $5,977.00 / $12,538.00
| Facility | | $3,877.00 | $5,977.00 | $12,538.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.47 / $1,401.73 / $2,143.58
| Professional | | $1,029.47 | $1,401.73 | $2,143.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,222.09 / $1,751.69 / $4,646.81
| Facility | | $1,222.09 | $1,751.69 | $4,646.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.67 / $1,556.48 / $2,407.45
| Professional | | $1,096.67 | $1,556.48 | $2,407.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,225.50 / $6,602.50 / $12,808.14
| Facility | | $3,225.50 | $6,602.50 | $12,808.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.72 / $1,402.12 / $2,393.67
| Professional | | $962.72 | $1,402.12 | $2,393.67 |