- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,975.02 / $6,607.00 / $10,492.00
| Facility | | $2,975.02 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,273.41 / $2,975.02 / $4,230.47
| Professional | | $2,273.41 | $2,975.02 | $4,230.47 |
- 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
- $1,631.83 / $3,414.06 / $4,050.62
| Professional | | $1,631.83 | $3,414.06 | $4,050.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.60 / $2,588.03 / $5,230.64
| Professional | | $2,065.60 | $2,588.03 | $5,230.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,281.84 / $2,702.70 / $2,702.70
| Professional | | $2,281.84 | $2,702.70 | $2,702.70 |
- 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
- $1,709.08 / $2,747.99 / $5,272.14
| Professional | | $1,709.08 | $2,747.99 | $5,272.14 |