- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,012.86 / $2,380.21 / $3,899.51
| Facility | | $1,012.86 | $2,380.21 | $3,899.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.00 / $1,012.86 / $1,038.18
| Professional | | $850.00 | $1,012.86 | $1,038.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $3,066.57
| Professional | | $1,440.00 | $1,440.00 | $3,066.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,266.07 / $3,703.26 / $36,395.72
| Facility | | $1,266.07 | $3,703.26 | $36,395.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.48 / $3,038.57 / $29,778.32
| Professional | | $1,323.48 | $3,038.57 | $29,778.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.16 / $2,666.36 / $8,535.71
| Facility | | $1,440.16 | $2,666.36 | $8,535.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.16 / $2,666.36 / $8,535.71
| Facility | | $1,440.16 | $2,666.36 | $8,535.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.75 / $759.64 / $1,672.10
| Professional | | $531.75 | $759.64 | $1,672.10 |