- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,039.21 / $10,900.00 / $14,552.94
| Facility | | $2,039.21 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,323.83 / $3,323.83 / $4,463.72
| Professional | | $3,323.83 | $3,323.83 | $4,463.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,370.61 / $2,370.61 / $2,370.61
| Professional | | $2,370.61 | $2,370.61 | $2,370.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.36 / $3,323.83 / $4,753.08
| Facility | | $860.36 | $3,323.83 | $4,753.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,727.30 / $4,485.60 / $5,633.68
| Professional | | $1,727.30 | $4,485.60 | $5,633.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.00 / $3,097.20 / $4,534.20
| Professional | | $2,670.00 | $3,097.20 | $4,534.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.36 / $3,323.83 / $4,753.08
| Facility | | $860.36 | $3,323.83 | $4,753.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.65 / $3,090.00 / $4,580.42
| Professional | | $975.65 | $3,090.00 | $4,580.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.90 / $1,896.48 / $4,368.76
| Professional | | $1,846.90 | $1,896.48 | $4,368.76 |