- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.49 / $5,695.00 / $10,871.00
| Facility | | $2,919.49 | $5,695.00 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,457.59 / $2,996.79 / $4,761.95
| Professional | | $2,457.59 | $2,996.79 | $4,761.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,700.16 / $19,158.88 / $21,611.98
| Facility | | $16,700.16 | $19,158.88 | $21,611.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,920.32 / $4,504.55 / $10,551.36
| Professional | | $2,920.32 | $4,504.55 | $10,551.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,848.07 / $3,916.31 / $5,050.18
| Professional | | $2,848.07 | $3,916.31 | $5,050.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,624.55 / $3,519.33 / $8,449.62
| Professional | | $2,624.55 | $3,519.33 | $8,449.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,846.00 / $7,273.00 / $10,536.00
| Facility | | $1,846.00 | $7,273.00 | $10,536.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,172.34 / $3,827.73 / $7,611.68
| Professional | | $2,172.34 | $3,827.73 | $7,611.68 |