- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,676.57 / $10,900.00 / $14,552.94
| Facility | | $6,676.57 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,207.38 / $11,029.57 / $11,029.57
| Professional | | $2,207.38 | $11,029.57 | $11,029.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,707.85 / $7,687.87 / $10,143.31
| Professional | | $5,707.85 | $7,687.87 | $10,143.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,207.38 / $11,029.57 / $15,441.40
| Facility | | $2,207.38 | $11,029.57 | $15,441.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,943.68 / $7,132.41 / $14,479.50
| Professional | | $5,943.68 | $7,132.41 | $14,479.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,653.80 / $10,669.26 / $14,118.00
| Professional | | $7,653.80 | $10,669.26 | $14,118.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,285.53 / $11,029.57 / $15,441.40
| Facility | | $2,285.53 | $11,029.57 | $15,441.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,460.68 / $10,669.26 / $16,129.82
| Professional | | $3,460.68 | $10,669.26 | $16,129.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,150.30 / $9,278.37 / $13,991.93
| Professional | | $6,150.30 | $9,278.37 | $13,991.93 |