- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,236.00 / $9,774.00 / $14,552.94
| Facility | | $2,236.00 | $9,774.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.44 / $2,296.58 / $2,296.58
| Professional | | $474.44 | $2,296.58 | $2,296.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.56 / $1,410.56 / $1,410.56
| Professional | | $1,410.56 | $1,410.56 | $1,410.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $518.51 / $2,296.58 / $3,284.11
| Facility | | $518.51 | $2,296.58 | $3,284.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.68 / $2,637.60 / $3,391.05
| Professional | | $1,015.68 | $2,637.60 | $3,391.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,570.00 / $1,821.20 / $2,659.80
| Professional | | $1,570.00 | $1,821.20 | $2,659.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $518.51 / $2,296.58 / $3,284.11
| Facility | | $518.51 | $2,296.58 | $3,284.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.42 / $1,797.00 / $2,682.69
| Professional | | $571.42 | $1,797.00 | $2,682.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.08 / $1,702.40 / $3,671.85
| Professional | | $1,055.08 | $1,702.40 | $3,671.85 |