- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,094.32 / $10,900.00 / $14,552.94
| Facility | | $1,094.32 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.01 / $2,000.63 / $2,000.63
| Professional | | $1,878.01 | $2,000.63 | $2,000.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.27 / $1,244.27 / $1,244.27
| Professional | | $1,244.27 | $1,244.27 | $1,244.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.58 / $2,000.63 / $2,860.90
| Facility | | $461.58 | $2,000.63 | $2,860.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.45 / $2,387.69 / $3,018.73
| Professional | | $919.45 | $2,387.69 | $3,018.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,421.25 / $1,839.25 / $3,069.90
| Professional | | $1,421.25 | $1,839.25 | $3,069.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.58 / $2,000.63 / $2,860.90
| Facility | | $461.58 | $2,000.63 | $2,860.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.23 / $1,576.50 / $2,551.48
| Professional | | $499.23 | $1,576.50 | $2,551.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.73 / $1,501.70 / $2,292.36
| Professional | | $965.73 | $1,501.70 | $2,292.36 |