- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.00 / $1,583.40 / $9,627.07
| Facility | | $1,421.00 | $1,583.40 | $9,627.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.40 / $1,624.00 / $2,030.00
| Professional | | $1,583.40 | $1,624.00 | $2,030.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,030.00 / $2,131.50 / $2,801.40
| Professional | | $2,030.00 | $2,131.50 | $2,801.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,689.32 / $5,000.91 / $11,574.65
| Facility | | $3,689.32 | $5,000.91 | $11,574.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.54 / $943.97 / $2,396.03
| Professional | | $916.54 | $943.97 | $2,396.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,583.40 / $2,030.00 / $2,943.50
| Facility | | $1,583.40 | $2,030.00 | $2,943.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.60 / $1,157.86 / $2,030.00
| Professional | | $852.60 | $1,157.86 | $2,030.00 |