- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,225.05 / $10,900.00 / $14,552.94
| Facility | | $1,225.05 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.40 / $2,352.96 / $2,352.96
| Professional | | $2,154.40 | $2,352.96 | $2,352.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,446.74 / $1,446.74 / $1,446.74
| Professional | | $1,446.74 | $1,446.74 | $1,446.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.79 / $2,352.96 / $3,364.75
| Facility | | $513.79 | $2,352.96 | $3,364.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.93 / $2,601.90 / $3,364.40
| Professional | | $1,001.93 | $2,601.90 | $3,364.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.75 / $1,796.55 / $2,760.74
| Professional | | $1,548.75 | $1,796.55 | $2,760.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.79 / $2,352.96 / $3,364.75
| Facility | | $513.79 | $2,352.96 | $3,364.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.64 / $1,846.50 / $2,902.50
| Professional | | $411.64 | $1,846.50 | $2,902.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.40 / $1,736.10 / $2,678.86
| Professional | | $1,157.40 | $1,736.10 | $2,678.86 |