- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,880.92 / $6,607.00 / $10,492.00
| Facility | | $2,880.92 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.39 / $2,880.92 / $4,022.74
| Professional | | $1,401.39 | $2,880.92 | $4,022.74 |
- 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
- $1,721.69 / $3,466.91 / $4,113.33
| Professional | | $1,721.69 | $3,466.91 | $4,113.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,038.01 / $2,660.93 / $4,622.14
| Professional | | $2,038.01 | $2,660.93 | $4,622.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,467.30 / $2,921.82 / $2,921.82
| Professional | | $2,467.30 | $2,921.82 | $2,921.82 |
- 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
- $1,752.15 / $2,876.85 / $5,353.52
| Professional | | $1,752.15 | $2,876.85 | $5,353.52 |