- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,236.00 / $9,813.00 / $14,552.94
| Facility | | $2,236.00 | $9,813.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.88 / $1,501.88 / $1,986.92
| Professional | | $1,501.88 | $1,501.88 | $1,986.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.09 / $1,058.09 / $1,058.09
| Professional | | $1,058.09 | $1,058.09 | $1,058.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $387.45 / $1,501.88 / $2,147.69
| Facility | | $387.45 | $1,501.88 | $2,147.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.48 / $1,959.30 / $2,538.90
| Professional | | $754.48 | $1,959.30 | $2,538.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.25 / $1,352.85 / $1,964.60
| Professional | | $1,166.25 | $1,352.85 | $1,964.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $387.45 / $1,501.88 / $2,147.69
| Facility | | $387.45 | $1,501.88 | $2,147.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.08 / $1,339.50 / $2,000.31
| Professional | | $426.08 | $1,339.50 | $2,000.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.62 / $846.48 / $1,944.65
| Professional | | $795.62 | $846.48 | $1,944.65 |