- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.43 / $4,370.00 / $10,871.00
| Facility | | $1,640.43 | $4,370.00 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.75 / $1,640.43 / $1,840.25
| Professional | | $1,389.75 | $1,640.43 | $1,840.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.82 / $2,339.71 / $4,966.16
| Professional | | $1,507.82 | $2,339.71 | $4,966.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,343.36 / $2,556.62 / $2,845.20
| Professional | | $2,343.36 | $2,556.62 | $2,845.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.08 / $1,578.80 / $3,134.01
| Professional | | $1,247.08 | $1,578.80 | $3,134.01 |
- 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
- $1,387.06 / $1,834.92 / $4,531.64
| Professional | | $1,387.06 | $1,834.92 | $4,531.64 |