- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,741.00 / $10,480.00 / $13,413.92
| Facility | | $3,741.00 | $10,480.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.33 / $1,714.46 / $1,815.66
| Professional | | $322.33 | $1,714.46 | $1,815.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.15 / $1,182.56 / $1,459.15
| Professional | | $873.15 | $1,182.56 | $1,459.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $322.35 / $1,714.46 / $2,400.23
| Facility | | $322.35 | $1,714.46 | $2,400.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.30 / $997.56 / $2,025.16
| Professional | | $831.30 | $997.56 | $2,025.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.25 / $1,732.04 / $2,237.40
| Professional | | $1,266.25 | $1,732.04 | $2,237.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $322.35 / $1,714.46 / $2,400.23
| Facility | | $322.35 | $1,714.46 | $2,400.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.52 / $1,687.95 / $2,695.05
| Professional | | $522.52 | $1,687.95 | $2,695.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.06 / $1,427.23 / $2,081.33
| Professional | | $946.06 | $1,427.23 | $2,081.33 |