- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,872.00 / $8,303.41 / $13,413.92
| Facility | | $1,872.00 | $8,303.41 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.23 / $2,203.38 / $2,203.38
| Professional | | $422.23 | $2,203.38 | $2,203.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.96 / $1,552.62 / $1,989.83
| Professional | | $1,156.96 | $1,552.62 | $1,989.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $431.74 / $2,203.38 / $3,084.73
| Facility | | $431.74 | $2,203.38 | $3,084.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.84 / $1,349.82 / $2,740.27
| Professional | | $1,124.84 | $1,349.82 | $2,740.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.00 / $2,027.13 / $2,836.00
| Professional | | $1,485.00 | $2,027.13 | $2,836.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $431.74 / $2,203.38 / $3,084.73
| Facility | | $431.74 | $2,203.38 | $3,084.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.82 / $2,027.13 / $3,240.13
| Professional | | $686.82 | $2,027.13 | $3,240.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.09 / $1,873.84 / $2,825.78
| Professional | | $1,242.09 | $1,873.84 | $2,825.78 |