- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,144.53 / $6,607.00 / $10,492.00
| Facility | | $2,144.53 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.89 / $2,144.53 / $3,475.17
| Professional | | $1,515.89 | $2,144.53 | $3,475.17 |
- 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
- $1,300.11 / $2,608.69 / $3,095.11
| Professional | | $1,300.11 | $2,608.69 | $3,095.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.16 / $1,897.57 / $3,611.34
| Professional | | $1,539.16 | $1,897.57 | $3,611.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.01 / $2,206.58 / $2,206.58
| Professional | | $1,847.01 | $2,206.58 | $2,206.58 |
- 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
- $1,295.55 / $2,012.48 / $4,042.21
| Professional | | $1,295.55 | $2,012.48 | $4,042.21 |