- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,574.09 / $9,813.00 / $14,552.94
| Facility | | $2,574.09 | $9,813.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.30 / $4,365.72 / $4,365.72
| Professional | | $832.30 | $4,365.72 | $4,365.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.60 / $4,365.72 / $6,112.02
| Facility | | $851.60 | $4,365.72 | $6,112.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.73 / $2,658.87 / $5,397.80
| Professional | | $2,215.73 | $2,658.87 | $5,397.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,211.25 / $4,446.20 / $5,432.00
| Professional | | $3,211.25 | $4,446.20 | $5,432.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.60 / $4,365.72 / $6,112.02
| Facility | | $851.60 | $4,365.72 | $6,112.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.12 / $4,443.45 / $5,665.00
| Professional | | $1,335.12 | $4,443.45 | $5,665.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,351.46 / $4,121.71 / $5,181.57
| Professional | | $2,351.46 | $4,121.71 | $5,181.57 |