- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,464.00 / $6,782.00 / $13,413.92
| Facility | | $2,464.00 | $6,782.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.64 / $1,683.64 / $2,360.67
| Professional | | $1,683.64 | $1,683.64 | $2,360.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.55 / $1,247.55 / $1,247.55
| Professional | | $1,247.55 | $1,247.55 | $1,247.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $451.11 / $1,683.64 / $2,407.61
| Facility | | $451.11 | $1,683.64 | $2,407.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.00 / $2,228.10 / $2,949.90
| Professional | | $858.00 | $2,228.10 | $2,949.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.25 / $1,538.45 / $2,290.19
| Professional | | $1,326.25 | $1,538.45 | $2,290.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $451.11 / $1,683.64 / $2,407.61
| Facility | | $451.11 | $1,683.64 | $2,407.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.58 / $1,551.00 / $2,312.51
| Professional | | $492.58 | $1,551.00 | $2,312.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.85 / $1,497.06 / $2,310.44
| Professional | | $897.85 | $1,497.06 | $2,310.44 |