- 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
- $581.51 / $3,022.88 / $3,022.88
| Professional | | $581.51 | $3,022.88 | $3,022.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.79 / $2,021.76 / $2,695.39
| Professional | | $1,518.79 | $2,021.76 | $2,695.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $595.42 / $3,022.88 / $4,232.03
| Facility | | $595.42 | $3,022.88 | $4,232.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.25 / $1,865.10 / $3,786.34
| Professional | | $1,554.25 | $1,865.10 | $3,786.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,236.25 / $3,080.00 / $3,808.00
| Professional | | $2,236.25 | $3,080.00 | $3,808.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $595.42 / $3,022.88 / $4,232.03
| Facility | | $595.42 | $3,022.88 | $4,232.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.58 / $3,046.40 / $3,929.20
| Professional | | $925.58 | $3,046.40 | $3,929.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,617.42 / $2,830.49 / $3,558.32
| Professional | | $1,617.42 | $2,830.49 | $3,558.32 |