- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,049.56 / $6,607.00 / $10,492.00
| Facility | | $4,049.56 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,837.41 / $4,049.56 / $6,463.38
| Professional | | $2,837.41 | $4,049.56 | $6,463.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,329.50 / $17,206.00 / $26,880.01
| Facility | | $8,329.50 | $17,206.00 | $26,880.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,397.80 / $4,855.76 / $5,761.14
| Professional | | $2,397.80 | $4,855.76 | $5,761.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,852.74 / $3,719.16 / $6,793.43
| Professional | | $2,852.74 | $3,719.16 | $6,793.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,450.68 / $4,067.74 / $4,067.74
| Professional | | $3,450.68 | $4,067.74 | $4,067.74 |
- 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
- $2,463.12 / $3,421.52 / $8,870.84
| Professional | | $2,463.12 | $3,421.52 | $8,870.84 |