- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,113.35 / $10,900.00 / $14,552.94
| Facility | | $2,113.35 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.12 / $3,584.30 / $3,584.30
| Professional | | $688.12 | $3,584.30 | $3,584.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,804.31 / $2,417.76 / $3,172.14
| Professional | | $1,804.31 | $2,417.76 | $3,172.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $726.76 / $3,584.30 / $5,018.02
| Facility | | $726.76 | $3,584.30 | $5,018.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.50 / $2,274.60 / $4,617.68
| Professional | | $1,895.50 | $2,274.60 | $4,617.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,651.25 / $3,663.60 / $4,494.00
| Professional | | $2,651.25 | $3,663.60 | $4,494.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $726.76 / $3,584.30 / $5,018.02
| Facility | | $726.76 | $3,584.30 | $5,018.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.84 / $3,621.00 / $4,688.20
| Professional | | $1,098.84 | $3,621.00 | $4,688.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.88 / $3,868.40 / $4,255.24
| Professional | | $1,933.88 | $3,868.40 | $4,255.24 |