- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,675.46 / $5,283.80 / $16,467.00
| Facility | | $2,675.46 | $5,283.80 | $16,467.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,914.07 / $2,675.46 / $5,283.80
| Professional | | $1,914.07 | $2,675.46 | $5,283.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.20 / $3,735.00 / $4,964.56
| Professional | | $1,788.20 | $3,735.00 | $4,964.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,242.55 / $2,701.16 / $4,440.79
| Professional | | $2,242.55 | $2,701.16 | $4,440.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,039.12 / $3,043.00 / $4,633.75
| Facility | | $2,039.12 | $3,043.00 | $4,633.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.39 / $1,842.94 / $2,943.48
| Professional | | $178.39 | $1,842.94 | $2,943.48 |
- 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
- $1,909.35 / $2,945.38 / $5,089.43
| Professional | | $1,909.35 | $2,945.38 | $5,089.43 |