- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,587.50 / $6,607.00 / $10,492.00
| Facility | | $2,587.50 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,957.00 / $2,587.50 / $3,754.24
| Professional | | $1,957.00 | $2,587.50 | $3,754.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,703.45 / $11,230.09 / $13,227.00
| Facility | | $8,703.45 | $11,230.09 | $13,227.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.32 / $3,294.06 / $3,733.63
| Professional | | $1,517.32 | $3,294.06 | $3,733.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,721.46 / $2,516.87 / $4,119.97
| Professional | | $1,721.46 | $2,516.87 | $4,119.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.44 / $2,116.44 / $2,560.83
| Professional | | $2,116.44 | $2,116.44 | $2,560.83 |
- 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
- $1,634.50 / $2,787.57 / $6,303.72
| Professional | | $1,634.50 | $2,787.57 | $6,303.72 |