- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,471.24 / $1,471.24 / $3,638.00
| Facility | | $1,471.24 | $1,471.24 | $3,638.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.30 / $1,471.24 / $1,503.85
| Professional | | $1,270.30 | $1,471.24 | $1,503.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,299.43 / $8,040.40 / $16,508.77
| Facility | | $5,299.43 | $8,040.40 | $16,508.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,374.23 / $3,077.45 / $12,257.39
| Facility | | $2,374.23 | $3,077.45 | $12,257.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,221.13 / $3,956.00 / $6,547.37
| Professional | | $2,221.13 | $3,956.00 | $6,547.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,735.00 / $4,974.00 / $8,812.00
| Facility | | $2,735.00 | $4,974.00 | $8,812.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,112.09 / $4,176.13 / $6,357.99
| Professional | | $2,112.09 | $4,176.13 | $6,357.99 |