- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,577.23 / $5,103.20 / $16,467.00
| Facility | | $2,577.23 | $5,103.20 | $16,467.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,848.20 / $2,577.23 / $2,957.12
| Professional | | $1,848.20 | $2,577.23 | $2,957.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,726.05 / $2,373.00 / $4,172.45
| Professional | | $1,726.05 | $2,373.00 | $4,172.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.82 / $2,677.46 / $4,340.47
| Professional | | $2,209.82 | $2,677.46 | $4,340.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,918.19 / $2,657.76 / $4,201.39
| Facility | | $1,918.19 | $2,657.76 | $4,201.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.39 / $1,771.05 / $2,827.72
| Professional | | $178.39 | $1,771.05 | $2,827.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,471.00 / $6,679.00 / $9,084.00
| Facility | | $1,471.00 | $6,679.00 | $9,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.25 / $2,546.44 / $5,060.88
| Professional | | $1,845.25 | $2,546.44 | $5,060.88 |