- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,131.00 / $7,016.00 / $13,151.00
| Facility | | $3,131.00 | $7,016.00 | $13,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.58 / $1,160.05 / $1,575.96
| Professional | | $1,049.58 | $1,160.05 | $1,575.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.61 / $1,946.61 / $1,946.61
| Professional | | $1,946.61 | $1,946.61 | $1,946.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $624.00 / $624.00 / $624.00
| Facility | | $624.00 | $624.00 | $624.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.49 / $1,680.49 / $1,680.49
| Professional | | $1,680.49 | $1,680.49 | $1,680.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.65 / $1,459.32 / $5,273.00
| Facility | | $1,055.65 | $1,459.32 | $5,273.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.86 / $2,082.73 / $9,707.44
| Professional | | $1,493.86 | $2,082.73 | $9,707.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,779.00 / $3,946.00 / $6,988.00
| Facility | | $1,779.00 | $3,946.00 | $6,988.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.11 / $2,031.94 / $2,746.16
| Professional | | $1,453.11 | $2,031.94 | $2,746.16 |