- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,966.50 / $6,607.00 / $10,492.00
| Facility | | $2,966.50 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.55 / $2,966.50 / $4,218.35
| Professional | | $2,215.55 | $2,966.50 | $4,218.35 |
- 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
- $1,625.48 / $3,349.38 / $3,973.89
| Professional | | $1,625.48 | $3,349.38 | $3,973.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.15 / $2,519.86 / $5,163.55
| Professional | | $2,041.15 | $2,519.86 | $5,163.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,221.83 / $2,690.94 / $2,690.94
| Professional | | $2,221.83 | $2,690.94 | $2,690.94 |
- 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
- $1,701.33 / $2,720.51 / $9,075.12
| Professional | | $1,701.33 | $2,720.51 | $9,075.12 |