- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,834.62 / $5,982.00 / $11,332.00
| Facility | | $2,834.62 | $5,982.00 | $11,332.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,471.35 / $2,834.62 / $3,204.74
| Professional | | $2,471.35 | $2,834.62 | $3,204.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.87 / $4,021.00 / $8,588.02
| Professional | | $2,589.87 | $4,021.00 | $8,588.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,037.12 / $4,408.87 / $4,906.53
| Professional | | $4,037.12 | $4,408.87 | $4,906.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,174.15 / $2,745.59 / $4,859.51
| Professional | | $2,174.15 | $2,745.59 | $4,859.51 |
- 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
- $2,392.33 / $3,136.62 / $7,420.27
| Professional | | $2,392.33 | $3,136.62 | $7,420.27 |