- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,739.41 / $9,813.00 / $14,552.94
| Facility | | $2,739.41 | $9,813.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.31 / $4,646.14 / $5,000.57
| Professional | | $890.31 | $4,646.14 | $5,000.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.48 / $3,126.01 / $4,114.04
| Professional | | $2,337.48 | $3,126.01 | $4,114.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $909.14 / $4,646.14 / $6,504.60
| Facility | | $909.14 | $4,646.14 | $6,504.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,368.58 / $2,842.29 / $5,770.13
| Professional | | $2,368.58 | $2,842.29 | $5,770.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,433.75 / $4,740.32 / $5,810.00
| Professional | | $3,433.75 | $4,740.32 | $5,810.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $909.14 / $4,646.14 / $6,504.60
| Facility | | $909.14 | $4,646.14 | $6,504.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,421.56 / $4,685.20 / $6,052.20
| Professional | | $1,421.56 | $4,685.20 | $6,052.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,473.61 / $4,286.20 / $5,501.76
| Professional | | $2,473.61 | $4,286.20 | $5,501.76 |