- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,872.00 / $8,303.41 / $13,413.92
| Facility | | $1,872.00 | $8,303.41 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.90 / $2,765.41 / $2,765.41
| Professional | | $531.90 | $2,765.41 | $2,765.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.75 / $1,843.82 / $2,472.67
| Professional | | $1,386.75 | $1,843.82 | $2,472.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $545.20 / $2,765.41 / $3,871.57
| Facility | | $545.20 | $2,765.41 | $3,871.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.05 / $1,708.86 / $3,469.17
| Professional | | $1,424.05 | $1,708.86 | $3,469.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,028.75 / $2,815.64 / $3,492.00
| Professional | | $2,028.75 | $2,815.64 | $3,492.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $545.20 / $2,765.41 / $3,871.57
| Facility | | $545.20 | $2,765.41 | $3,871.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.59 / $2,782.90 / $3,586.00
| Professional | | $846.59 | $2,782.90 | $3,586.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.06 / $2,950.12 / $3,245.13
| Professional | | $1,475.06 | $2,950.12 | $3,245.13 |