- 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
- $5,148.08 / $5,375.65 / $5,375.65
| Professional | | $5,148.08 | $5,375.65 | $5,375.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.31 / $1,049.31 / $3,170.22
| Professional | | $1,049.31 | $1,049.31 | $3,170.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,182.30 / $1,433.93 / $7,687.18
| Facility | | $1,182.30 | $1,433.93 | $7,687.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,347.55 / $2,817.06 / $6,724.86
| Professional | | $2,347.55 | $2,817.06 | $6,724.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,426.25 / $3,937.95 / $5,312.49
| Professional | | $3,426.25 | $3,937.95 | $5,312.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,433.93 / $1,433.93 / $7,687.18
| Facility | | $1,433.93 | $1,433.93 | $7,687.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.31 / $4,468.20 / $6,158.25
| Professional | | $1,049.31 | $4,468.20 | $6,158.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,520.48 / $2,536.17 / $3,804.27
| Professional | | $2,520.48 | $2,536.17 | $3,804.27 |