- 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
- $944.60 / $4,940.84 / $4,940.84
| Professional | | $944.60 | $4,940.84 | $4,940.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,491.90 / $3,339.03 / $4,347.35
| Professional | | $2,491.90 | $3,339.03 | $4,347.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $961.68 / $4,940.84 / $6,917.18
| Facility | | $961.68 | $4,940.84 | $6,917.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,501.19 / $3,001.44 / $6,093.21
| Professional | | $2,501.19 | $3,001.44 | $6,093.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,561.25 / $4,746.20 / $6,132.00
| Professional | | $3,561.25 | $4,746.20 | $6,132.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $961.68 / $4,940.84 / $6,917.18
| Facility | | $961.68 | $4,940.84 | $6,917.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.54 / $4,476.14 / $6,426.20
| Professional | | $1,509.54 | $4,476.14 | $6,426.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,664.04 / $4,674.64 / $5,876.68
| Professional | | $2,664.04 | $4,674.64 | $5,876.68 |