- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,596.67 / $6,986.00 / $12,831.00
| Facility | | $2,596.67 | $6,986.00 | $12,831.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.33 / $2,243.23 / $2,774.70
| Professional | | $1,938.33 | $2,243.23 | $2,774.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,864.31 / $2,742.89 / $5,485.78
| Professional | | $1,864.31 | $2,742.89 | $5,485.78 |
- 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
- $1,947.62 / $3,058.86 / $6,808.13
| Professional | | $1,947.62 | $3,058.86 | $6,808.13 |