- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,513.53 / $6,986.00 / $12,831.00
| Facility | | $2,513.53 | $6,986.00 | $12,831.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,876.28 / $2,160.80 / $2,685.83
| Professional | | $1,876.28 | $2,160.80 | $2,685.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,804.62 / $2,640.91 / $5,368.70
| Professional | | $1,804.62 | $2,640.91 | $5,368.70 |
- 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
- $1,858.74 / $2,615.80 / $6,385.80
| Professional | | $1,858.74 | $2,615.80 | $6,385.80 |