- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,766.19 / $7,655.00 / $13,151.00
| Facility | | $2,766.19 | $7,655.00 | $13,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.15 / $1,665.15 / $2,766.19
| Professional | | $1,665.15 | $1,665.15 | $2,766.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,156.00 / $1,620.02 / $3,411.80
| Facility | | $1,156.00 | $1,620.02 | $3,411.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,475.21 / $2,912.02 / $2,912.02
| Professional | | $2,475.21 | $2,912.02 | $2,912.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,792.60 / $2,858.05 / $3,877.04
| Professional | | $1,792.60 | $2,858.05 | $3,877.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,642.84 / $7,208.00
| Facility | | $55.00 | $2,642.84 | $7,208.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,028.51 / $2,542.88 / $14,283.70
| Professional | | $2,028.51 | $2,542.88 | $14,283.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,967.00 / $4,960.00 / $11,732.00
| Facility | | $1,967.00 | $4,960.00 | $11,732.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,956.06 / $2,326.38 / $3,536.66
| Professional | | $1,956.06 | $2,326.38 | $3,536.66 |