- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,965.08 / $5,982.00 / $11,298.00
| Facility | | $1,965.08 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.83 / $1,943.51 / $2,084.73
| Professional | | $1,658.83 | $1,943.51 | $2,084.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.63 / $2,654.38 / $5,512.26
| Professional | | $1,688.63 | $2,654.38 | $5,512.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,606.55 / $2,872.83 / $3,197.11
| Professional | | $2,606.55 | $2,872.83 | $3,197.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.64 / $1,775.74 / $3,534.29
| Professional | | $1,402.64 | $1,775.74 | $3,534.29 |
- 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
- $1,551.47 / $2,052.42 / $5,062.04
| Professional | | $1,551.47 | $2,052.42 | $5,062.04 |