- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,394.75 / $7,193.00 / $17,263.20
| Facility | | $5,394.75 | $7,193.00 | $17,263.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,322.82 / $5,394.75 / $7,696.51
| Professional | | $5,322.82 | $5,394.75 | $7,696.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,833.35 / $6,833.35 / $6,833.35
| Professional | | $6,833.35 | $6,833.35 | $6,833.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,675.45 / $4,675.45 / $19,216.09
| Facility | | $4,675.45 | $4,675.45 | $19,216.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,003.07 / $3,836.99 / $10,497.02
| Professional | | $3,003.07 | $3,836.99 | $10,497.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,322.82 / $7,193.00 / $12,084.24
| Facility | | $5,322.82 | $7,193.00 | $12,084.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.06 / $3,021.06 / $10,789.50
| Professional | | $3,021.06 | $3,021.06 | $10,789.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.06 / $3,021.06 / $4,603.52
| Professional | | $3,021.06 | $3,021.06 | $4,603.52 |