- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,287.35 / $7,273.73 / $11,239.40
| Facility | | $4,287.35 | $7,273.73 | $11,239.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.59 / $1,865.59 / $4,531.00
| Professional | | $1,865.59 | $1,865.59 | $4,531.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,626.30 / $3,626.30 / $3,626.30
| Professional | | $3,626.30 | $3,626.30 | $3,626.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,313.55 / $3,706.56 / $7,981.29
| Facility | | $2,313.55 | $3,706.56 | $7,981.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,762.55 / $4,085.37 / $5,137.05
| Professional | | $1,762.55 | $4,085.37 | $5,137.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,340.80 / $3,027.20 / $6,124.80
| Facility | | $2,340.80 | $3,027.20 | $6,124.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.40 / $2,112.00 / $5,984.00
| Professional | | $1,478.40 | $2,112.00 | $5,984.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.40 / $2,112.00 / $5,984.00
| Professional | | $1,478.40 | $2,112.00 | $5,984.00 |