- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,377.47 / $4,112.00 / $4,933.00
| Facility | | $1,377.47 | $4,112.00 | $4,933.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.90 / $1,308.57 / $1,377.47
| Professional | | $869.90 | $1,308.57 | $1,377.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,942.91 / $2,942.91 / $2,942.91
| Facility | | $2,942.91 | $2,942.91 | $2,942.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,795.76 / $3,060.63 / $3,972.93
| Professional | | $2,795.76 | $3,060.63 | $3,972.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,945.40 / $4,112.00 / $4,933.00
| Facility | | $1,945.40 | $4,112.00 | $4,933.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.47 / $1,945.40 / $2,551.00
| Professional | | $1,377.47 | $1,945.40 | $2,551.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,296.00 / $7,780.00 / $10,556.00
| Facility | | $3,296.00 | $7,780.00 | $10,556.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.34 / $2,640.06 / $3,701.52
| Professional | | $2,098.34 | $2,640.06 | $3,701.52 |