- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,760.00 / $4,470.00 / $12,154.00
| Facility | | $1,760.00 | $4,470.00 | $12,154.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.32 / $2,040.12 / $2,345.75
| Professional | | $1,641.32 | $2,040.12 | $2,345.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,224.00 / $4,449.00 / $10,043.00
| Facility | | $2,224.00 | $4,449.00 | $10,043.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.28 / $2,190.42 / $3,534.74
| Professional | | $1,807.28 | $2,190.42 | $3,534.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,594.89 / $2,566.63 / $4,718.14
| Professional | | $1,594.89 | $2,566.63 | $4,718.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $958.00 / $2,539.66 / $7,903.00
| Facility | | $958.00 | $2,539.66 | $7,903.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,021.54 / $3,273.39 / $13,333.20
| Professional | | $2,021.54 | $3,273.39 | $13,333.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.00 / $3,233.00 / $11,343.00
| Facility | | $1,185.00 | $3,233.00 | $11,343.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.98 / $2,507.98 / $4,143.76
| Professional | | $1,737.98 | $2,507.98 | $4,143.76 |