- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,236.00 / $9,813.00 / $14,552.94
| Facility | | $2,236.00 | $9,813.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.42 / $3,023.26 / $3,023.26
| Professional | | $581.42 | $3,023.26 | $3,023.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.75 / $2,021.71 / $2,698.61
| Professional | | $1,518.75 | $2,021.71 | $2,698.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $596.19 / $3,023.26 / $4,232.56
| Facility | | $596.19 | $3,023.26 | $4,232.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.68 / $1,868.01 / $3,792.25
| Professional | | $1,556.68 | $1,868.01 | $3,792.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,203.75 / $3,085.68 / $3,814.00
| Professional | | $2,203.75 | $3,085.68 | $3,814.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $596.19 / $3,023.26 / $4,232.56
| Facility | | $596.19 | $3,023.26 | $4,232.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.06 / $3,049.80 / $3,933.60
| Professional | | $926.06 | $3,049.80 | $3,933.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.53 / $2,772.08 / $3,558.24
| Professional | | $789.53 | $2,772.08 | $3,558.24 |