- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,052.76 / $10,900.00 / $14,552.94
| Facility | | $2,052.76 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.20 / $3,481.56 / $3,481.56
| Professional | | $667.20 | $3,481.56 | $3,481.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,749.68 / $2,324.38 / $3,091.68
| Professional | | $1,749.68 | $2,324.38 | $3,091.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $686.14 / $3,481.56 / $4,874.18
| Facility | | $686.14 | $3,481.56 | $4,874.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,789.58 / $2,147.48 / $4,359.60
| Professional | | $1,789.58 | $2,147.48 | $4,359.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,556.25 / $3,529.44 / $4,366.00
| Professional | | $2,556.25 | $3,529.44 | $4,366.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $686.14 / $3,481.56 / $4,874.18
| Facility | | $686.14 | $3,481.56 | $4,874.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.35 / $3,488.40 / $4,468.20
| Professional | | $1,066.35 | $3,488.40 | $4,468.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,856.71 / $3,187.05 / $4,090.90
| Professional | | $1,856.71 | $3,187.05 | $4,090.90 |