- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,687.88 / $5,503.00 / $10,651.00
| Facility | | $2,687.88 | $5,503.00 | $10,651.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.86 / $2,687.88 / $3,842.69
| Professional | | $2,272.86 | $2,687.88 | $3,842.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,948.00 / $14,105.00 / $28,800.00
| Facility | | $9,948.00 | $14,105.00 | $28,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,592.07 / $3,204.63 / $4,641.82
| Professional | | $2,592.07 | $3,204.63 | $4,641.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,822.46 / $3,584.00 / $4,750.06
| Professional | | $2,822.46 | $3,584.00 | $4,750.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,687.88 / $3,225.46 / $4,515.64
| Facility | | $2,687.88 | $3,225.46 | $4,515.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,460.09 / $3,507.90 / $4,510.16
| Professional | | $2,460.09 | $3,507.90 | $4,510.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,292.00 / $8,535.00 / $12,740.00
| Facility | | $1,292.00 | $8,535.00 | $12,740.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,843.72 / $3,879.72 / $6,547.84
| Professional | | $2,843.72 | $3,879.72 | $6,547.84 |