- 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
- $530.97 / $2,760.58 / $2,760.58
| Professional | | $530.97 | $2,760.58 | $2,760.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.01 / $1,841.46 / $2,468.29
| Professional | | $1,385.01 | $1,841.46 | $2,468.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $544.58 / $2,760.58 / $3,864.81
| Facility | | $544.58 | $2,760.58 | $3,864.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.43 / $1,706.91 / $3,465.23
| Professional | | $1,422.43 | $1,706.91 | $3,465.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,038.75 / $2,779.50 / $3,484.00
| Professional | | $2,038.75 | $2,779.50 | $3,484.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $544.58 / $2,760.58 / $3,864.81
| Facility | | $544.58 | $2,760.58 | $3,864.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.88 / $2,756.25 / $3,546.40
| Professional | | $844.88 | $2,756.25 | $3,546.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.16 / $2,578.03 / $3,240.95
| Professional | | $1,473.16 | $2,578.03 | $3,240.95 |