- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,764.49 / $6,275.61 / $16,467.00
| Facility | | $2,764.49 | $6,275.61 | $16,467.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,273.79 / $2,764.49 / $3,638.06
| Professional | | $2,273.79 | $2,764.49 | $3,638.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,103.00 / $2,234.88 / $3,740.65
| Professional | | $2,103.00 | $2,234.88 | $3,740.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.74 / $3,238.47 / $5,681.96
| Professional | | $1,851.74 | $3,238.47 | $5,681.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.12 / $2,764.49 / $5,195.39
| Facility | | $2,155.12 | $2,764.49 | $5,195.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.96 / $1,809.75 / $3,288.45
| Professional | | $252.96 | $1,809.75 | $3,288.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $659.00 / $6,107.00 / $8,818.00
| Facility | | $659.00 | $6,107.00 | $8,818.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.21 / $3,124.31 / $5,629.82
| Professional | | $2,138.21 | $3,124.31 | $5,629.82 |