- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,152.53 / $3,008.50 / $7,325.50
| Facility | | $1,152.53 | $3,008.50 | $7,325.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.37 / $1,140.36 / $1,880.08
| Professional | | $1,011.37 | $1,140.36 | $1,880.08 |
- 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
- $1,069.04 / $1,457.42 / $2,224.19
| Professional | | $1,069.04 | $1,457.42 | $2,224.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,268.11 / $1,771.42 / $3,666.22
| Facility | | $1,268.11 | $1,771.42 | $3,666.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.84 / $1,601.28 / $2,497.69
| Professional | | $1,141.84 | $1,601.28 | $2,497.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $6,231.00 / $11,869.99
| Facility | | $2,912.00 | $6,231.00 | $11,869.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.26 / $1,466.86 / $2,483.27
| Professional | | $1,007.26 | $1,466.86 | $2,483.27 |