- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,878.48 / $6,607.00 / $10,492.00
| Facility | | $3,878.48 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,321.24 / $3,878.48 / $5,685.69
| Professional | | $3,321.24 | $3,878.48 | $5,685.69 |
- 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
- $2,254.86 / $5,292.49 / $6,056.95
| Professional | | $2,254.86 | $5,292.49 | $6,056.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,689.42 / $3,782.73 / $6,077.00
| Professional | | $2,689.42 | $3,782.73 | $6,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,597.12 / $3,597.12 / $3,803.33
| Professional | | $3,597.12 | $3,597.12 | $3,803.33 |
- 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
- $2,451.92 / $3,739.03 / $8,851.93
| Professional | | $2,451.92 | $3,739.03 | $8,851.93 |