- 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
- $773.80 / $3,374.88 / $4,361.51
| Professional | | $773.80 | $3,374.88 | $4,361.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,391.10 / $2,391.10 / $2,391.10
| Professional | | $2,391.10 | $2,391.10 | $2,391.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.22 / $3,374.88 / $4,826.08
| Facility | | $875.22 | $3,374.88 | $4,826.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,727.30 / $4,485.60 / $5,770.64
| Professional | | $1,727.30 | $4,485.60 | $5,770.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.00 / $3,097.20 / $4,346.00
| Professional | | $2,670.00 | $3,097.20 | $4,346.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.22 / $3,374.88 / $4,826.08
| Facility | | $875.22 | $3,374.88 | $4,826.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.33 / $3,066.00 / $4,386.41
| Professional | | $934.33 | $3,066.00 | $4,386.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.65 / $2,869.32 / $4,268.71
| Professional | | $1,832.65 | $2,869.32 | $4,268.71 |