- 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
- $734.20 / $3,834.72 / $3,834.72
| Professional | | $734.20 | $3,834.72 | $3,834.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.28 / $2,582.67 / $3,393.72
| Professional | | $1,930.28 | $2,582.67 | $3,393.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $750.61 / $3,834.72 / $5,368.61
| Facility | | $750.61 | $3,834.72 | $5,368.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,955.35 / $2,346.42 / $4,763.46
| Professional | | $1,955.35 | $2,346.42 | $4,763.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,831.25 / $3,916.44 / $4,792.00
| Professional | | $2,831.25 | $3,916.44 | $4,792.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $750.61 / $3,834.72 / $5,368.61
| Facility | | $750.61 | $3,834.72 | $5,368.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.11 / $3,870.90 / $5,000.60
| Professional | | $1,173.11 | $3,870.90 | $5,000.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.94 / $3,615.75 / $4,545.51
| Professional | | $2,062.94 | $3,615.75 | $4,545.51 |