- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,105.25 / $8,303.41 / $13,413.92
| Facility | | $3,105.25 | $8,303.41 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.12 / $5,129.82 / $5,129.82
| Professional | | $993.12 | $5,129.82 | $5,129.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,661.93 / $3,578.14 / $4,602.16
| Professional | | $2,661.93 | $3,578.14 | $4,602.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.95 / $5,129.82 / $7,181.75
| Facility | | $1,018.95 | $5,129.82 | $7,181.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.13 / $3,174.15 / $6,443.87
| Professional | | $2,645.13 | $3,174.15 | $6,443.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,436.40 / $4,743.68 / $6,300.00
| Professional | | $3,436.40 | $4,743.68 | $6,300.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.95 / $5,129.82 / $7,181.75
| Facility | | $1,018.95 | $5,129.82 | $7,181.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,608.25 / $4,743.68 / $7,140.63
| Professional | | $1,608.25 | $4,743.68 | $7,140.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,808.14 / $12,808.14 / $12,808.14
| Facility | | $12,808.14 | $12,808.14 | $12,808.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,862.52 / $4,318.41 / $7,156.30
| Professional | | $2,862.52 | $4,318.41 | $7,156.30 |