- 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
- $500.01 / $2,617.37 / $2,617.37
| Professional | | $500.01 | $2,617.37 | $2,617.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.47 / $1,811.75 / $2,292.14
| Professional | | $1,322.47 | $1,811.75 | $2,292.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.70 / $2,617.37 / $3,664.32
| Facility | | $513.70 | $2,617.37 | $3,664.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.10 / $1,602.12 / $3,252.47
| Professional | | $1,335.10 | $1,602.12 | $3,252.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.00 / $2,733.08 / $3,242.00
| Professional | | $1,980.00 | $2,733.08 | $3,242.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.70 / $2,617.37 / $3,664.32
| Facility | | $513.70 | $2,617.37 | $3,664.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.60 / $2,534.40 / $3,544.20
| Professional | | $801.60 | $2,534.40 | $3,544.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.40 / $2,536.44 / $3,188.68
| Professional | | $1,449.40 | $2,536.44 | $3,188.68 |