- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,475.39 / $5,695.00 / $10,871.00
| Facility | | $2,475.39 | $5,695.00 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,088.23 / $2,516.75 / $4,467.97
| Professional | | $2,088.23 | $2,516.75 | $4,467.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,522.35 / $3,618.01 / $6,976.71
| Professional | | $2,522.35 | $3,618.01 | $6,976.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,560.11 / $3,784.32 / $4,433.79
| Professional | | $2,560.11 | $3,784.32 | $4,433.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,555.58 / $3,228.11 / $6,732.11
| Professional | | $2,555.58 | $3,228.11 | $6,732.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,066.00 / $12,315.00 / $27,214.00
| Facility | | $6,066.00 | $12,315.00 | $27,214.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,157.36 / $3,139.71 / $8,193.53
| Professional | | $2,157.36 | $3,139.71 | $8,193.53 |