- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,874.34 / $6,607.00 / $10,492.00
| Facility | | $2,874.34 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,261.71 / $2,874.34 / $4,659.18
| Professional | | $2,261.71 | $2,874.34 | $4,659.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,098.00 / $12,905.00 / $17,206.00
| Facility | | $12,098.00 | $12,905.00 | $17,206.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.04 / $3,847.26 / $4,402.97
| Professional | | $1,697.04 | $3,847.26 | $4,402.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,955.11 / $2,872.42 / $4,649.39
| Professional | | $1,955.11 | $2,872.42 | $4,649.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,452.25 / $2,452.25 / $2,865.43
| Professional | | $2,452.25 | $2,452.25 | $2,865.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,275.00 / $5,345.00 / $9,973.00
| Facility | | $3,275.00 | $5,345.00 | $9,973.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.86 / $2,919.35 / $5,524.33
| Professional | | $1,826.86 | $2,919.35 | $5,524.33 |