- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,810.66 / $6,628.00 / $11,798.00
| Facility | | $1,810.66 | $6,628.00 | $11,798.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.75 / $1,906.52 / $3,472.92
| Professional | | $1,652.75 | $1,906.52 | $3,472.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,924.67 / $2,701.45 / $5,612.16
| Professional | | $1,924.67 | $2,701.45 | $5,612.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.82 / $2,773.50 / $3,576.50
| Professional | | $2,031.82 | $2,773.50 | $3,576.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,606.42 / $14,382.16 / $27,428.23
| Facility | | $11,606.42 | $14,382.16 | $27,428.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.76 / $2,373.26 / $4,556.34
| Professional | | $1,657.76 | $2,373.26 | $4,556.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,474.00 / $8,558.00 / $15,604.00
| Facility | | $3,474.00 | $8,558.00 | $15,604.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.39 / $2,332.44 / $5,775.51
| Professional | | $1,639.39 | $2,332.44 | $5,775.51 |