- 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
- $487.77 / $1,004.56 / $2,777.03
| Professional | | $487.77 | $1,004.56 | $2,777.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.65 / $1,853.85 / $2,479.34
| Professional | | $1,393.65 | $1,853.85 | $2,479.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $546.66 / $2,777.03 / $3,887.84
| Facility | | $546.66 | $2,777.03 | $3,887.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.30 / $1,712.76 / $3,477.05
| Professional | | $1,427.30 | $1,712.76 | $3,477.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.25 / $2,827.68 / $3,498.00
| Professional | | $2,041.25 | $2,827.68 | $3,498.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $546.66 / $2,777.03 / $3,887.84
| Facility | | $546.66 | $2,777.03 | $3,887.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.53 / $2,794.80 / $3,601.40
| Professional | | $849.53 | $2,794.80 | $3,601.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.05 / $2,541.90 / $3,262.78
| Professional | | $729.05 | $2,541.90 | $3,262.78 |