- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $10,964.78 / $16,595.87
| Facility | | $1,905.46 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $812.83 / $1,905.46
| Professional | | $588.84 | $812.83 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $2,818.38
| Professional | | $1,584.89 | $2,137.96 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,000.00 / $4,466.84
| Facility | | $588.84 | $1,000.00 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,238.72 / $3,388.44
| Professional | | $1,548.82 | $2,238.72 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,691.53 / $3,715.35
| Professional | | $2,041.74 | $2,691.53 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $977.24 / $3,467.37
| Facility | | $602.56 | $977.24 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $870.96 / $2,137.96
| Professional | | $60.26 | $870.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,884.03 / $3,715.35
| Professional | | $741.31 | $2,884.03 | $3,715.35 |