- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,474.91 / $5,982.00 / $11,298.00
| Facility | | $2,474.91 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,087.23 / $2,474.91 / $2,803.08
| Professional | | $2,087.23 | $2,474.91 | $2,803.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.60 / $3,538.43 / $7,475.53
| Professional | | $2,255.60 | $3,538.43 | $7,475.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,538.49 / $3,876.15 / $4,313.68
| Professional | | $3,538.49 | $3,876.15 | $4,313.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.57 / $2,406.13 / $4,159.84
| Professional | | $1,900.57 | $2,406.13 | $4,159.84 |
- 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
- $2,105.31 / $2,776.97 / $6,927.29
| Professional | | $2,105.31 | $2,776.97 | $6,927.29 |