- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,078.42 / $5,982.00 / $11,298.00
| Facility | | $2,078.42 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.58 / $2,078.42 / $2,278.07
| Professional | | $1,767.58 | $2,078.42 | $2,278.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.94 / $2,860.61 / $6,022.49
| Professional | | $1,847.94 | $2,860.61 | $6,022.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,864.52 / $3,153.21 / $3,509.14
| Professional | | $2,864.52 | $3,153.21 | $3,509.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.27 / $1,947.45 / $3,901.55
| Professional | | $1,538.27 | $1,947.45 | $3,901.55 |
- 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
- $1,719.09 / $2,253.94 / $5,606.75
| Professional | | $1,719.09 | $2,253.94 | $5,606.75 |