- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,556.73 / $6,607.00 / $10,492.00
| Facility | | $2,556.73 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.39 / $2,556.73 / $4,134.37
| Professional | | $2,125.39 | $2,556.73 | $4,134.37 |
- 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
- $1,594.09 / $3,333.93 / $4,039.94
| Professional | | $1,594.09 | $3,333.93 | $4,039.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.94 / $2,511.48 / $5,062.74
| Professional | | $2,002.94 | $2,511.48 | $5,062.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,221.03 / $2,639.58 / $2,639.58
| Professional | | $2,221.03 | $2,639.58 | $2,639.58 |
- 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
- $1,660.13 / $2,422.79 / $4,836.89
| Professional | | $1,660.13 | $2,422.79 | $4,836.89 |