- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,045.32 / $6,607.00 / $10,492.00
| Facility | | $2,045.32 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.86 / $2,045.32 / $2,908.45
| Professional | | $1,565.86 | $2,045.32 | $2,908.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,927.44 / $14,057.22 / $19,128.36
| Facility | | $5,927.44 | $14,057.22 | $19,128.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.75 / $2,345.13 / $2,782.38
| Professional | | $1,131.75 | $2,345.13 | $2,782.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,418.67 / $1,777.84 / $3,588.37
| Professional | | $1,418.67 | $1,777.84 | $3,588.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.43 / $1,873.54 / $1,873.54
| Professional | | $1,573.43 | $1,873.54 | $1,873.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,275.00 / $6,137.00 / $16,193.00
| Facility | | $3,275.00 | $6,137.00 | $16,193.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.07 / $1,848.17 / $3,628.03
| Professional | | $1,188.07 | $1,848.17 | $3,628.03 |