- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,236.00 / $10,175.36 / $14,552.94
| Facility | | $2,236.00 | $10,175.36 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.53 / $2,172.32 / $2,172.32
| Professional | | $422.53 | $2,172.32 | $2,172.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.40 / $1,458.38 / $1,929.99
| Professional | | $1,098.40 | $1,458.38 | $1,929.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.54 / $2,172.32 / $3,041.25
| Facility | | $426.54 | $2,172.32 | $3,041.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.09 / $1,333.32 / $2,706.78
| Professional | | $1,111.09 | $1,333.32 | $2,706.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,592.50 / $2,222.23 / $2,736.00
| Professional | | $1,592.50 | $2,222.23 | $2,736.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.54 / $2,172.32 / $3,041.25
| Facility | | $426.54 | $2,172.32 | $3,041.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.60 / $2,196.40 / $2,796.20
| Professional | | $664.60 | $2,196.40 | $2,796.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.06 / $2,041.73 / $2,566.73
| Professional | | $1,165.06 | $2,041.73 | $2,566.73 |