- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,604.16 / $7,340.00 / $13,413.92
| Facility | | $1,604.16 | $7,340.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.75 / $1,097.32 / $2,706.58
| Professional | | $293.75 | $1,097.32 | $2,706.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.66 / $960.09 / $1,792.96
| Professional | | $661.66 | $960.09 | $1,792.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,851.41 / $2,647.52 / $3,789.21
| Facility | | $1,851.41 | $2,647.52 | $3,789.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.28 / $1,212.35 / $1,686.54
| Professional | | $941.28 | $1,212.35 | $1,686.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.36 / $1,650.00 / $2,429.71
| Professional | | $927.36 | $1,650.00 | $2,429.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,851.41 / $2,647.52 / $3,789.21
| Facility | | $1,851.41 | $2,647.52 | $3,789.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.84 / $1,439.10 / $2,634.66
| Professional | | $701.84 | $1,439.10 | $2,634.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.91 / $1,434.36 / $2,163.88
| Professional | | $620.91 | $1,434.36 | $2,163.88 |