- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,126.02 / $9,813.00 / $14,552.94
| Facility | | $3,126.02 | $9,813.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.85 / $5,095.27 / $5,655.44
| Professional | | $1,043.85 | $5,095.27 | $5,655.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,384.37 / $3,384.37 / $3,384.37
| Professional | | $3,384.37 | $3,384.37 | $3,384.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,284.02 / $5,095.27 / $7,286.24
| Facility | | $1,284.02 | $5,095.27 | $7,286.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,678.30 / $6,955.20 / $8,524.87
| Professional | | $2,678.30 | $6,955.20 | $8,524.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,140.00 / $4,802.39 / $6,329.40
| Professional | | $4,140.00 | $4,802.39 | $6,329.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,284.02 / $5,095.27 / $7,286.24
| Facility | | $1,284.02 | $5,095.27 | $7,286.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.80 / $4,551.00 / $6,618.64
| Professional | | $1,409.80 | $4,551.00 | $6,618.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,831.32 / $11,831.32 / $11,831.32
| Facility | | $11,831.32 | $11,831.32 | $11,831.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,576.44 / $2,886.89 / $5,925.81
| Professional | | $2,576.44 | $2,886.89 | $5,925.81 |