- 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
- $444.71 / $2,304.46 / $2,304.46
| Professional | | $444.71 | $2,304.46 | $2,304.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.55 / $1,523.67 / $2,076.21
| Professional | | $1,150.55 | $1,523.67 | $2,076.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.16 / $2,304.46 / $3,226.26
| Facility | | $458.16 | $2,304.46 | $3,226.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.25 / $1,439.10 / $2,921.51
| Professional | | $1,199.25 | $1,439.10 | $2,921.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.75 / $2,260.00 / $2,942.00
| Professional | | $1,693.75 | $2,260.00 | $2,942.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.16 / $2,304.46 / $3,226.26
| Facility | | $458.16 | $2,304.46 | $3,226.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.82 / $2,260.00 / $2,970.00
| Professional | | $707.82 | $2,260.00 | $2,970.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.94 / $2,133.15 / $2,681.67
| Professional | | $1,218.94 | $2,133.15 | $2,681.67 |