- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,236.00 / $9,774.00 / $14,552.94
| Facility | | $2,236.00 | $9,774.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.55 / $2,107.25 / $2,107.25
| Professional | | $413.55 | $2,107.25 | $2,107.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.16 / $1,376.81 / $1,938.90
| Professional | | $1,061.16 | $1,376.81 | $1,938.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $413.55 / $2,107.25 / $2,950.15
| Facility | | $413.55 | $2,107.25 | $2,950.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.23 / $1,302.27 / $2,643.74
| Professional | | $1,085.23 | $1,302.27 | $2,643.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,673.75 / $2,142.40 / $2,740.00
| Professional | | $1,673.75 | $2,142.40 | $2,740.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $413.55 / $2,107.25 / $2,950.15
| Facility | | $413.55 | $2,107.25 | $2,950.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.02 / $2,141.40 / $2,943.60
| Professional | | $639.02 | $2,141.40 | $2,943.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.46 / $1,927.56 / $2,423.21
| Professional | | $1,101.46 | $1,927.56 | $2,423.21 |