- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,250.80 / $6,607.00 / $10,492.00
| Facility | | $3,250.80 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.37 / $3,250.80 / $4,726.04
| Professional | | $2,554.37 | $3,250.80 | $4,726.04 |
- 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
- $1,907.72 / $4,347.93 / $4,975.97
| Professional | | $1,907.72 | $4,347.93 | $4,975.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,192.19 / $3,178.26 / $5,227.53
| Professional | | $2,192.19 | $3,178.26 | $5,227.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,762.32 / $2,762.32 / $3,225.21
| Professional | | $2,762.32 | $2,762.32 | $3,225.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,275.00 / $5,345.00 / $14,963.00
| Facility | | $3,275.00 | $5,345.00 | $14,963.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,063.60 / $3,478.78 / $6,229.17
| Professional | | $2,063.60 | $3,478.78 | $6,229.17 |