- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,306.48 / $2,394.07 / $12,986.40
| Facility | | $2,306.48 | $2,394.07 | $12,986.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.72 / $2,335.67 / $2,919.60
| Professional | | $2,043.72 | $2,335.67 | $2,919.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.00 / $846.27 / $846.27
| Professional | | $680.00 | $846.27 | $846.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,503.52 / $38,319.75 / $73,573.92
| Facility | | $3,503.52 | $38,319.75 | $73,573.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,357.54 / $4,087.44 / $54,154.15
| Professional | | $3,357.54 | $4,087.44 | $54,154.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.74 / $2,271.73 / $3,852.41
| Facility | | $1,897.74 | $2,271.73 | $3,852.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.35 / $14,072.47 / $14,072.47
| Professional | | $3,388.35 | $14,072.47 | $14,072.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.19 / $1,751.76 / $2,919.60
| Professional | | $1,264.19 | $1,751.76 | $2,919.60 |