- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,347.46 / $4,510.50 / $9,450.50
| Facility | | $1,347.46 | $4,510.50 | $9,450.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.64 / $1,168.48 / $1,899.10
| Professional | | $1,072.64 | $1,168.48 | $1,899.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,877.00 / $7,264.00 / $12,274.00
| Facility | | $3,877.00 | $7,264.00 | $12,274.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.51 / $1,395.45 / $2,326.41
| Professional | | $1,119.51 | $1,395.45 | $2,326.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,053.13 / $3,616.93 / $4,048.71
| Facility | | $3,053.13 | $3,616.93 | $4,048.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,176.35 / $1,704.80 / $2,848.07
| Professional | | $1,176.35 | $1,704.80 | $2,848.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,059.00 / $6,527.50 / $12,055.49
| Facility | | $3,059.00 | $6,527.50 | $12,055.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.58 / $1,577.76 / $2,618.61
| Professional | | $1,117.58 | $1,577.76 | $2,618.61 |