- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,687.00 / $2,018.91 / $2,997.89
| Facility | | $1,687.00 | $2,018.91 | $2,997.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.18 / $2,018.91 / $2,687.85
| Professional | | $1,331.18 | $2,018.91 | $2,687.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,783.10 / $8,674.20 / $11,969.08
| Facility | | $4,783.10 | $8,674.20 | $11,969.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.71 / $2,015.15 / $2,943.30
| Professional | | $1,631.71 | $2,015.15 | $2,943.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $1,111.76
| Facility | | $40.00 | $40.00 | $1,111.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $400.00 / $400.00
| Facility | | $400.00 | $400.00 | $400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.17 / $2,084.23 / $2,961.35
| Professional | | $1,396.17 | $2,084.23 | $2,961.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.00 / $4,717.00 / $11,696.00
| Facility | | $1,141.00 | $4,717.00 | $11,696.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.72 / $1,949.61 / $3,392.73
| Professional | | $1,461.72 | $1,949.61 | $3,392.73 |