- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,054.58 / $6,607.00 / $10,492.00
| Facility | | $2,054.58 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.52 / $2,054.58 / $2,921.61
| Professional | | $1,588.52 | $2,054.58 | $2,921.61 |
- 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
- $1,145.11 / $2,376.42 / $2,819.51
| Professional | | $1,145.11 | $2,376.42 | $2,819.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.42 / $1,799.84 / $3,630.61
| Professional | | $1,435.42 | $1,799.84 | $3,630.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.25 / $1,896.75 / $1,896.75
| Professional | | $1,596.25 | $1,896.75 | $1,896.75 |
- 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
- $1,202.14 / $1,913.33 / $3,670.80
| Professional | | $1,202.14 | $1,913.33 | $3,670.80 |