- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.92 / $9,774.00 / $14,552.94
| Facility | | $2,282.92 | $9,774.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.98 / $3,871.89 / $3,871.89
| Professional | | $742.98 | $3,871.89 | $3,871.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,948.13 / $2,599.87 / $3,432.52
| Professional | | $1,948.13 | $2,599.87 | $3,432.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.91 / $3,871.89 / $5,420.65
| Facility | | $758.91 | $3,871.89 | $5,420.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.00 / $2,373.60 / $4,818.62
| Professional | | $1,978.00 | $2,373.60 | $4,818.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.75 / $3,907.75 / $4,846.00
| Professional | | $2,823.75 | $3,907.75 | $4,846.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.91 / $3,871.89 / $5,420.65
| Facility | | $758.91 | $3,871.89 | $5,420.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.30 / $3,901.50 / $5,022.60
| Professional | | $1,184.30 | $3,901.50 | $5,022.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.17 / $3,639.83 / $4,575.78
| Professional | | $2,070.17 | $3,639.83 | $4,575.78 |