- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,734.72 / $6,628.00 / $11,798.00
| Facility | | $2,734.72 | $6,628.00 | $11,798.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,413.23 / $2,734.72 / $4,756.09
| Professional | | $2,413.23 | $2,734.72 | $4,756.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,699.42 / $3,917.46 / $8,630.26
| Professional | | $2,699.42 | $3,917.46 | $8,630.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,580.94 / $3,969.75 / $4,462.81
| Professional | | $2,580.94 | $3,969.75 | $4,462.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,528.30 / $3,398.25 / $7,066.72
| Professional | | $2,528.30 | $3,398.25 | $7,066.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,682.00 / $10,536.00 / $23,291.00
| Facility | | $5,682.00 | $10,536.00 | $23,291.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,276.76 / $3,490.10 / $8,364.09
| Professional | | $2,276.76 | $3,490.10 | $8,364.09 |