- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,977.50 / $6,607.00 / $10,492.00
| Facility | | $2,977.50 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,195.19 / $2,977.50 / $4,341.01
| Professional | | $2,195.19 | $2,977.50 | $4,341.01 |
- 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
- $1,746.30 / $3,715.35 / $4,211.14
| Professional | | $1,746.30 | $3,715.35 | $4,211.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.77 / $2,927.16 / $4,686.56
| Professional | | $2,001.77 | $2,927.16 | $4,686.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,379.37 / $2,379.37 / $2,943.91
| Professional | | $2,379.37 | $2,379.37 | $2,943.91 |
- 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
- $1,894.40 / $3,168.43 / $6,858.35
| Professional | | $1,894.40 | $3,168.43 | $6,858.35 |