- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.30 / $6,607.00 / $10,492.00
| Facility | | $2,290.30 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,536.77 / $2,290.30 / $3,568.49
| Professional | | $1,536.77 | $2,290.30 | $3,568.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,897.58 / $15,915.00 / $22,259.10
| Facility | | $6,897.58 | $15,915.00 | $22,259.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.30 / $2,914.01 / $3,457.34
| Professional | | $1,381.30 | $2,914.01 | $3,457.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.89 / $2,404.36 / $3,600.67
| Professional | | $1,718.89 | $2,404.36 | $3,600.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.45 / $2,307.73 / $2,307.73
| Professional | | $1,869.45 | $2,307.73 | $2,307.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,275.00 / $6,137.00 / $16,193.00
| Facility | | $3,275.00 | $6,137.00 | $16,193.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.30 / $2,197.31 / $3,890.91
| Professional | | $1,457.30 | $2,197.31 | $3,890.91 |