- 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
- $540.58 / $1,715.14 / $2,908.95
| Professional | | $540.58 | $1,715.14 | $2,908.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.60 / $1,942.68 / $2,598.44
| Professional | | $1,460.60 | $1,942.68 | $2,598.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $573.50 / $2,908.95 / $4,072.53
| Facility | | $573.50 | $2,908.95 | $4,072.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,497.65 / $1,797.18 / $3,648.44
| Professional | | $1,497.65 | $1,797.18 | $3,648.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.75 / $2,965.28 / $3,672.00
| Professional | | $2,138.75 | $2,965.28 | $3,672.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $573.50 / $2,908.95 / $4,072.53
| Facility | | $573.50 | $2,908.95 | $4,072.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.08 / $2,930.80 / $3,777.40
| Professional | | $891.08 | $2,930.80 | $3,777.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.14 / $3,108.28 / $3,419.11
| Professional | | $1,554.14 | $3,108.28 | $3,419.11 |