- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.85 / $1,560.09 / $9,034.00
| Facility | | $1,055.85 | $1,560.09 | $9,034.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.37 / $1,055.85 / $1,349.86
| Professional | | $785.37 | $1,055.85 | $1,349.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,027.36 / $3,027.36 / $3,632.83
| Facility | | $3,027.36 | $3,027.36 | $3,632.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.67 / $1,183.33 / $1,252.94
| Professional | | $946.67 | $1,183.33 | $1,252.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,849.45 / $2,849.45 / $2,849.45
| Facility | | $2,849.45 | $2,849.45 | $2,849.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.62 / $1,293.29 / $1,652.79
| Professional | | $845.62 | $1,293.29 | $1,652.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,268.00 / $5,626.00
| Facility | | $1,240.00 | $2,268.00 | $5,626.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.42 / $1,072.91 / $1,668.92
| Professional | | $804.42 | $1,072.91 | $1,668.92 |