- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $12,022.64 / $16,595.87
| Facility | | $2,754.23 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,174.90 / $2,754.23
| Professional | | $707.95 | $1,174.90 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,090.30 / $3,981.07
| Professional | | $2,290.87 | $3,090.30 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,318.26 / $6,309.57
| Facility | | $831.76 | $1,318.26 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,162.28 / $4,786.30
| Professional | | $2,137.96 | $3,162.28 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,801.89 / $5,370.32
| Professional | | $2,951.21 | $3,801.89 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $5,011.87
| Facility | | $870.96 | $1,230.27 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,288.25 / $3,090.30
| Professional | | $60.26 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $4,073.80 / $5,370.32
| Professional | | $1,000.00 | $4,073.80 | $5,370.32 |