- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,047.85 / $5,899.06 / $10,871.00
| Facility | | $3,047.85 | $5,899.06 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,047.85 / $3,547.88 / $5,899.06
| Professional | | $3,047.85 | $3,547.88 | $5,899.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,705.61 / $14,024.65 / $16,886.06
| Professional | | $11,705.61 | $14,024.65 | $16,886.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,270.66 / $5,521.51 / $6,682.66
| Professional | | $4,270.66 | $5,521.51 | $6,682.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,910.19 / $4,126.67 / $7,108.55
| Professional | | $2,910.19 | $4,126.67 | $7,108.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,627.00 / $6,590.00 / $10,536.00
| Facility | | $1,627.00 | $6,590.00 | $10,536.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,346.26 / $3,752.60 / $7,772.54
| Professional | | $2,346.26 | $3,752.60 | $7,772.54 |