- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,335.46 / $10,900.00 / $14,552.94
| Facility | | $2,335.46 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,806.70 / $3,806.70 / $5,099.22
| Professional | | $3,806.70 | $3,806.70 | $5,099.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,712.45 / $2,712.45 / $2,712.45
| Professional | | $2,712.45 | $2,712.45 | $2,712.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $984.94 / $3,806.70 / $5,443.58
| Facility | | $984.94 | $3,806.70 | $5,443.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,977.18 / $5,134.50 / $6,453.66
| Professional | | $1,977.18 | $5,134.50 | $6,453.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,056.25 / $3,545.25 / $5,178.80
| Professional | | $3,056.25 | $3,545.25 | $5,178.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $984.94 / $3,806.70 / $5,443.58
| Facility | | $984.94 | $3,806.70 | $5,443.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.45 / $3,534.00 / $5,222.66
| Professional | | $1,112.45 | $3,534.00 | $5,222.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.52 / $2,169.96 / $5,424.90
| Professional | | $2,077.52 | $2,169.96 | $5,424.90 |