- 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
- $467.84 / $2,421.13 / $2,421.13
| Professional | | $467.84 | $2,421.13 | $2,421.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.76 / $1,602.32 / $2,188.65
| Professional | | $1,209.76 | $1,602.32 | $2,188.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.47 / $2,421.13 / $3,389.58
| Facility | | $482.47 | $2,421.13 | $3,389.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.95 / $1,516.74 / $3,079.11
| Professional | | $1,263.95 | $1,516.74 | $3,079.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.00 / $2,402.00 / $3,094.00
| Professional | | $1,790.00 | $2,402.00 | $3,094.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.47 / $2,421.13 / $3,389.58
| Facility | | $482.47 | $2,421.13 | $3,389.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.58 / $2,285.50 / $3,141.60
| Professional | | $742.58 | $2,285.50 | $3,141.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.20 / $2,243.26 / $2,820.09
| Professional | | $640.20 | $2,243.26 | $2,820.09 |