- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,453.82 / $10,900.00 / $14,552.94
| Facility | | $1,453.82 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.36 / $2,792.38 / $2,792.38
| Professional | | $2,612.36 | $2,792.38 | $2,792.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.57 / $1,748.57 / $1,748.57
| Professional | | $1,748.57 | $1,748.57 | $1,748.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $609.32 / $2,792.38 / $3,993.10
| Facility | | $609.32 | $2,792.38 | $3,993.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.50 / $3,078.60 / $3,993.21
| Professional | | $1,185.50 | $3,078.60 | $3,993.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.50 / $2,125.69 / $3,351.69
| Professional | | $1,832.50 | $2,125.69 | $3,351.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $609.32 / $2,792.38 / $3,993.10
| Facility | | $609.32 | $2,792.38 | $3,993.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.75 / $2,230.50 / $3,436.64
| Professional | | $499.75 | $2,230.50 | $3,436.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.86 / $2,098.29 / $3,245.94
| Professional | | $1,398.86 | $2,098.29 | $3,245.94 |