- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,464.00 / $6,782.00 / $13,413.92
| Facility | | $2,464.00 | $6,782.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.68 / $2,028.23 / $2,028.23
| Professional | | $391.68 | $2,028.23 | $2,028.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.37 / $1,348.58 / $1,826.65
| Professional | | $1,016.37 | $1,348.58 | $1,826.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.91 / $2,028.23 / $2,839.52
| Facility | | $402.91 | $2,028.23 | $2,839.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.50 / $1,265.40 / $2,568.88
| Professional | | $1,054.50 | $1,265.40 | $2,568.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.25 / $2,072.60 / $2,586.00
| Professional | | $1,496.25 | $2,072.60 | $2,586.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.91 / $2,028.23 / $2,839.52
| Facility | | $402.91 | $2,028.23 | $2,839.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.48 / $2,048.50 / $2,642.20
| Professional | | $622.48 | $2,048.50 | $2,642.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.85 / $1,888.01 / $2,373.48
| Professional | | $1,078.85 | $1,888.01 | $2,373.48 |