- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,973.76 / $6,607.00 / $10,492.00
| Facility | | $2,973.76 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.17 / $2,973.76 / $4,326.93
| Professional | | $2,171.17 | $2,973.76 | $4,326.93 |
- 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
- $1,699.46 / $3,729.53 / $4,227.21
| Professional | | $1,699.46 | $3,729.53 | $4,227.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.05 / $2,864.88 / $4,612.47
| Professional | | $1,959.05 | $2,864.88 | $4,612.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,354.81 / $2,354.81 / $2,881.13
| Professional | | $2,354.81 | $2,354.81 | $2,881.13 |
- 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
- $1,855.01 / $2,861.61 / $5,576.74
| Professional | | $1,855.01 | $2,861.61 | $5,576.74 |