- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,741.00 / $10,175.36 / $13,413.92
| Facility | | $3,741.00 | $10,175.36 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.54 / $2,876.72 / $2,876.72
| Professional | | $532.54 | $2,876.72 | $2,876.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.73 / $1,966.73 / $2,451.67
| Professional | | $1,453.73 | $1,966.73 | $2,451.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.77 / $2,876.72 / $4,027.41
| Facility | | $542.77 | $2,876.72 | $4,027.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.85 / $1,684.62 / $3,419.92
| Professional | | $1,403.85 | $1,684.62 | $3,419.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.50 / $2,862.08 / $3,446.00
| Professional | | $2,077.50 | $2,862.08 | $3,446.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.77 / $2,876.72 / $4,027.41
| Facility | | $542.77 | $2,876.72 | $4,027.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.22 / $2,806.65 / $3,638.80
| Professional | | $884.22 | $2,806.65 | $3,638.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.90 / $2,753.42 / $3,461.44
| Professional | | $1,564.90 | $2,753.42 | $3,461.44 |