- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,236.00 / $9,813.00 / $14,552.94
| Facility | | $2,236.00 | $9,813.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,783.62 / $2,783.62 / $3,555.74
| Professional | | $2,783.62 | $2,783.62 | $3,555.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.03 / $1,958.03 / $1,958.03
| Professional | | $1,958.03 | $1,958.03 | $1,958.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $721.63 / $2,783.62 / $3,980.58
| Facility | | $721.63 | $2,783.62 | $3,980.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,432.95 / $3,721.20 / $4,758.72
| Professional | | $1,432.95 | $3,721.20 | $4,758.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.00 / $2,569.40 / $3,520.00
| Professional | | $2,215.00 | $2,569.40 | $3,520.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $721.63 / $2,783.62 / $3,980.58
| Facility | | $721.63 | $2,783.62 | $3,980.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.03 / $2,521.50 / $3,610.37
| Professional | | $769.03 | $2,521.50 | $3,610.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.08 / $2,349.63 / $3,480.08
| Professional | | $1,513.08 | $2,349.63 | $3,480.08 |