- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,274.42 / $1,821.00 / $3,324.00
| Facility | | $1,274.42 | $1,821.00 | $3,324.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.01 / $1,274.42 / $1,512.54
| Professional | | $1,000.01 | $1,274.42 | $1,512.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,029.72 / $3,029.72 / $3,635.66
| Facility | | $3,029.72 | $3,029.72 | $3,635.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.70 / $1,250.33 / $1,250.33
| Professional | | $944.70 | $1,250.33 | $1,250.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,711.31 / $4,711.31 / $4,711.31
| Facility | | $4,711.31 | $4,711.31 | $4,711.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.54 / $1,717.02 / $2,029.14
| Professional | | $1,164.54 | $1,717.02 | $2,029.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,311.00 / $5,626.00
| Facility | | $1,240.00 | $2,311.00 | $5,626.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.65 / $1,262.48 / $1,980.72
| Professional | | $892.65 | $1,262.48 | $1,980.72 |