- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,720.30 / $10,900.00 / $14,552.94
| Facility | | $1,720.30 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,720.64 / $2,720.64 / $3,752.01
| Professional | | $2,720.64 | $2,720.64 | $3,752.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,990.14 / $1,990.14 / $1,990.14
| Professional | | $1,990.14 | $1,990.14 | $1,990.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $731.48 / $2,720.64 / $3,890.52
| Facility | | $731.48 | $2,720.64 | $3,890.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.05 / $3,698.10 / $4,784.39
| Professional | | $1,424.05 | $3,698.10 | $4,784.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,201.25 / $2,553.44 / $3,704.80
| Professional | | $2,201.25 | $2,553.44 | $3,704.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $731.48 / $2,720.64 / $3,890.52
| Facility | | $731.48 | $2,720.64 | $3,890.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.95 / $2,520.00 / $3,750.86
| Professional | | $798.95 | $2,520.00 | $3,750.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.10 / $2,388.17 / $3,672.18
| Professional | | $1,482.10 | $2,388.17 | $3,672.18 |