- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,034.67 / $10,900.00 / $14,552.94
| Facility | | $3,034.67 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.27 / $1,153.76 / $5,547.98
| Professional | | $1,046.27 | $1,153.76 | $5,547.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.55 / $1,585.76 / $3,511.57
| Professional | | $1,023.55 | $1,585.76 | $3,511.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.48 / $5,547.98 / $7,767.17
| Facility | | $1,060.48 | $5,547.98 | $7,767.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,588.53 / $3,829.41 / $7,077.24
| Professional | | $2,588.53 | $3,829.41 | $7,077.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,740.01 / $4,929.60 / $7,898.47
| Professional | | $2,740.01 | $4,929.60 | $7,898.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.48 / $5,547.98 / $7,767.17
| Facility | | $1,060.48 | $5,547.98 | $7,767.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.40 / $3,807.60 / $6,778.60
| Professional | | $1,262.40 | $3,807.60 | $6,778.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.51 / $2,809.26 / $7,748.89
| Professional | | $1,407.51 | $2,809.26 | $7,748.89 |