- 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
- $854.14 / $4,460.60 / $4,460.60
| Professional | | $854.14 | $4,460.60 | $4,460.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,247.66 / $3,005.06 / $3,937.50
| Professional | | $2,247.66 | $3,005.06 | $3,937.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.18 / $4,460.60 / $6,244.84
| Facility | | $870.18 | $4,460.60 | $6,244.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,265.08 / $2,718.09 / $5,517.97
| Professional | | $2,265.08 | $2,718.09 | $5,517.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,300.00 / $4,545.96 / $5,558.00
| Professional | | $3,300.00 | $4,545.96 | $5,558.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.18 / $4,460.60 / $6,244.84
| Facility | | $870.18 | $4,460.60 | $6,244.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.74 / $4,493.10 / $5,790.40
| Professional | | $1,363.74 | $4,493.10 | $5,790.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.60 / $4,207.07 / $5,288.89
| Professional | | $2,395.60 | $4,207.07 | $5,288.89 |