- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,993.84 / $6,607.00 / $10,492.00
| Facility | | $1,993.84 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.46 / $1,993.84 / $2,767.62
| Professional | | $1,334.46 | $1,993.84 | $2,767.62 |
- 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
- $1,086.99 / $1,928.46 / $2,393.83
| Professional | | $1,086.99 | $1,928.46 | $2,393.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.82 / $1,513.54 / $3,342.84
| Professional | | $1,304.82 | $1,513.54 | $3,342.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.46 / $1,824.67 / $1,824.67
| Professional | | $1,333.46 | $1,824.67 | $1,824.67 |
- 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
- $1,083.18 / $1,817.48 / $3,486.91
| Professional | | $1,083.18 | $1,817.48 | $3,486.91 |