- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,043.95 / $7,340.00 / $13,413.92
| Facility | | $2,043.95 | $7,340.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,448.62 / $3,788.73 / $4,101.06
| Professional | | $3,448.62 | $3,788.73 | $4,101.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.43 / $1,488.89 / $2,771.55
| Professional | | $1,238.43 | $1,488.89 | $2,771.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,448.62 / $4,828.07 / $5,741.48
| Facility | | $3,448.62 | $4,828.07 | $5,741.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.70 / $2,116.44 / $2,553.12
| Professional | | $1,763.70 | $2,116.44 | $2,553.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.39 / $3,049.04 / $3,705.00
| Professional | | $1,736.39 | $3,049.04 | $3,705.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,448.62 / $4,828.07 / $5,741.48
| Facility | | $3,448.62 | $4,828.07 | $5,741.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.43 / $2,562.58 / $4,727.67
| Professional | | $1,238.43 | $2,562.58 | $4,727.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.19 / $2,217.23 / $3,344.94
| Professional | | $946.19 | $2,217.23 | $3,344.94 |