- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,285.00 / $10,900.00 / $14,552.94
| Facility | | $9,285.00 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,180.69 / $2,180.69 / $2,180.69
| Professional | | $2,180.69 | $2,180.69 | $2,180.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.08 / $1,271.08 / $1,271.08
| Professional | | $1,271.08 | $1,271.08 | $1,271.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,180.69 / $3,052.98 / $3,118.40
| Facility | | $2,180.69 | $3,052.98 | $3,118.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.07 / $373.07 / $532.95
| Professional | | $373.07 | $373.07 | $532.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.50 / $1,853.10 / $2,502.06
| Professional | | $1,597.50 | $1,853.10 | $2,502.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,180.69 / $3,052.98 / $3,118.40
| Facility | | $2,180.69 | $3,052.98 | $3,118.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.08 / $1,970.10 / $2,670.36
| Professional | | $1,271.08 | $1,970.10 | $2,670.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.68 / $1,187.49 / $1,816.26
| Professional | | $789.68 | $1,187.49 | $1,816.26 |