- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,025.14 / $6,607.00 / $10,492.00
| Facility | | $2,025.14 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.09 / $2,025.14 / $2,863.30
| Professional | | $1,541.09 | $2,025.14 | $2,863.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,021.45 / $11,075.34 / $12,977.57
| Facility | | $4,021.45 | $11,075.34 | $12,977.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.68 / $2,254.71 / $2,675.11
| Professional | | $1,094.68 | $2,254.71 | $2,675.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.34 / $1,719.84 / $3,469.20
| Professional | | $1,373.34 | $1,719.84 | $3,469.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.07 / $1,813.28 / $1,813.28
| Professional | | $1,549.07 | $1,813.28 | $1,813.28 |
- 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
- $1,149.45 / $1,787.76 / $3,510.69
| Professional | | $1,149.45 | $1,787.76 | $3,510.69 |