- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.63 / $10,900.00 / $14,552.94
| Facility | | $2,238.63 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.42 / $3,796.79 / $3,796.79
| Professional | | $752.42 | $3,796.79 | $3,796.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,909.43 / $2,441.96 / $3,485.78
| Professional | | $1,909.43 | $2,441.96 | $3,485.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $752.42 / $3,796.79 / $5,315.51
| Facility | | $752.42 | $3,796.79 | $5,315.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,952.93 / $2,343.51 / $4,709.25
| Professional | | $1,952.93 | $2,343.51 | $4,709.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.25 / $3,611.90 / $4,710.20
| Professional | | $2,666.25 | $3,611.90 | $4,710.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $752.42 / $3,796.79 / $5,315.51
| Facility | | $752.42 | $3,796.79 | $5,315.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.26 / $3,412.80 / $4,710.20
| Professional | | $1,149.26 | $3,412.80 | $4,710.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.28 / $3,348.30 / $4,297.88
| Professional | | $1,895.28 | $3,348.30 | $4,297.88 |