- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,873.00 / $5,809.50 / $24,101.30
| Facility | | $3,873.00 | $5,809.50 | $24,101.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.02 / $3,059.67 / $3,873.00
| Professional | | $2,066.02 | $3,059.67 | $3,873.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,785.86 / $8,536.74 / $17,747.43
| Facility | | $3,785.86 | $8,536.74 | $17,747.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,174.76 / $4,136.33 / $7,014.82
| Professional | | $2,174.76 | $4,136.33 | $7,014.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $4,066.65 / $5,615.85
| Professional | | $2,711.10 | $4,066.65 | $5,615.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,207.00 / $13,785.00 / $13,785.00
| Facility | | $4,207.00 | $13,785.00 | $13,785.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,820.31 / $3,873.00 / $7,949.60
| Facility | | $1,820.31 | $3,873.00 | $7,949.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.20 / $2,323.80 / $3,950.46
| Professional | | $1,549.20 | $2,323.80 | $3,950.46 |