- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,817.63 / $6,607.00 / $10,492.00
| Facility | | $2,817.63 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,305.23 / $2,817.63 / $4,106.89
| Professional | | $2,305.23 | $2,817.63 | $4,106.89 |
- 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
- $1,647.12 / $3,867.40 / $4,426.02
| Professional | | $1,647.12 | $3,867.40 | $4,426.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.91 / $2,820.56 / $4,409.60
| Professional | | $1,965.91 | $2,820.56 | $4,409.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,490.67 / $2,490.67 / $2,779.59
| Professional | | $2,490.67 | $2,490.67 | $2,779.59 |
- 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
- $1,787.52 / $2,943.30 / $6,469.17
| Professional | | $1,787.52 | $2,943.30 | $6,469.17 |