- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.07 / $5,982.00 / $11,298.00
| Facility | | $2,116.07 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.16 / $2,116.07 / $2,433.40
| Professional | | $1,770.16 | $2,116.07 | $2,433.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.52 / $2,920.75 / $6,687.83
| Professional | | $1,810.52 | $2,920.75 | $6,687.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,794.38 / $3,080.49 / $3,428.22
| Professional | | $2,794.38 | $3,080.49 | $3,428.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,504.53 / $1,904.74 / $3,858.97
| Professional | | $1,504.53 | $1,904.74 | $3,858.97 |
- 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
- $1,665.92 / $2,228.13 / $5,483.79
| Professional | | $1,665.92 | $2,228.13 | $5,483.79 |