- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,426.00 / $4,265.20 / $8,240.00
| Facility | | $1,426.00 | $4,265.20 | $8,240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,605.86 / $1,811.41 / $1,811.41
| Professional | | $1,605.86 | $1,811.41 | $1,811.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.30 / $2,116.30 / $2,116.30
| Professional | | $2,116.30 | $2,116.30 | $2,116.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,589.34 / $7,589.34 / $7,589.34
| Facility | | $7,589.34 | $7,589.34 | $7,589.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.00 / $4,597.00 / $8,404.00
| Facility | | $1,020.00 | $4,597.00 | $8,404.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.00 / $1,811.41 / $4,386.37
| Professional | | $1,426.00 | $1,811.41 | $4,386.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.30 / $2,116.30 / $2,116.30
| Professional | | $2,116.30 | $2,116.30 | $2,116.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.00 / $2,824.00 / $5,678.00
| Facility | | $1,747.00 | $2,824.00 | $5,678.00 |