- 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
- $438.56 / $2,272.51 / $2,272.51
| Professional | | $438.56 | $2,272.51 | $2,272.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.67 / $1,512.90 / $2,044.47
| Professional | | $1,139.67 | $1,512.90 | $2,044.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.62 / $2,272.51 / $3,181.51
| Facility | | $450.62 | $2,272.51 | $3,181.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.03 / $1,414.83 / $2,872.26
| Professional | | $1,179.03 | $1,414.83 | $2,872.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.75 / $2,323.71 / $2,894.00
| Professional | | $1,683.75 | $2,323.71 | $2,894.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.62 / $2,272.51 / $3,181.51
| Facility | | $450.62 | $2,272.51 | $3,181.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.12 / $2,296.69 / $2,961.20
| Professional | | $697.12 | $2,296.69 | $2,961.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.78 / $2,074.40 / $2,662.70
| Professional | | $1,205.78 | $2,074.40 | $2,662.70 |