- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,125.71 / $10,900.00 / $14,552.94
| Facility | | $2,125.71 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.45 / $3,361.82 / $3,741.87
| Professional | | $732.45 | $3,361.82 | $3,741.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,496.71 / $2,496.71 / $2,496.71
| Professional | | $2,496.71 | $2,496.71 | $2,496.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.46 / $3,361.82 / $4,807.39
| Facility | | $900.46 | $3,361.82 | $4,807.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.08 / $4,433.10 / $5,892.71
| Professional | | $1,707.08 | $4,433.10 | $5,892.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,638.75 / $3,060.95 / $4,562.80
| Professional | | $2,638.75 | $3,060.95 | $4,562.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.46 / $3,361.82 / $4,807.39
| Facility | | $900.46 | $3,361.82 | $4,807.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.30 / $3,096.00 / $4,611.64
| Professional | | $982.30 | $3,096.00 | $4,611.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.11 / $2,996.07 / $4,618.12
| Professional | | $1,787.11 | $2,996.07 | $4,618.12 |