- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,709.40 / $6,607.00 / $10,492.00
| Facility | | $2,709.40 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,388.35 / $2,709.40 / $4,308.88
| Professional | | $2,388.35 | $2,709.40 | $4,308.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,755.84 / $15,054.00 / $18,574.58
| Facility | | $5,755.84 | $15,054.00 | $18,574.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.91 / $3,586.54 / $4,255.26
| Professional | | $1,698.91 | $3,586.54 | $4,255.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,237.84 / $2,878.54 / $4,728.97
| Professional | | $2,237.84 | $2,878.54 | $4,728.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,621.00 / $3,081.36 / $3,081.36
| Professional | | $2,621.00 | $3,081.36 | $3,081.36 |
- 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
- $1,928.14 / $2,638.51 / $5,362.38
| Professional | | $1,928.14 | $2,638.51 | $5,362.38 |