- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,820.02 / $10,900.00 / $14,552.94
| Facility | | $1,820.02 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,934.48 / $2,934.48 / $3,760.47
| Professional | | $2,934.48 | $2,934.48 | $3,760.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.30 / $2,068.30 / $2,068.30
| Professional | | $2,068.30 | $2,068.30 | $2,068.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.78 / $2,934.48 / $4,196.31
| Facility | | $760.78 | $2,934.48 | $4,196.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.98 / $3,918.60 / $5,016.31
| Professional | | $1,508.98 | $3,918.60 | $5,016.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,332.50 / $2,705.70 / $3,720.20
| Professional | | $2,332.50 | $2,705.70 | $3,720.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.78 / $2,934.48 / $4,196.31
| Facility | | $760.78 | $2,934.48 | $4,196.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.73 / $2,662.50 / $3,815.53
| Professional | | $812.73 | $2,662.50 | $3,815.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,600.20 / $2,481.96 / $3,680.46
| Professional | | $1,600.20 | $2,481.96 | $3,680.46 |