- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,022.64 / $12,302.69
| Facility | | $12,022.64 | $12,022.64 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,148.15 / $4,570.88
| Professional | | $977.24 | $1,148.15 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,230.27 / $1,548.82
| Professional | | $1,096.48 | $1,230.27 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $2,454.71
| Professional | | $1,000.00 | $1,348.96 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $2,238.72
| Professional | | $1,071.52 | $1,202.26 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $2,884.03
| Facility | | $776.25 | $1,047.13 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $2,238.72
| Professional | | $870.96 | $1,230.27 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,288.25 / $1,659.59
| Professional | | $1,047.13 | $1,288.25 | $1,659.59 |