- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,652.60 / $5,982.00 / $11,298.00
| Facility | | $1,652.60 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.42 / $1,652.60 / $1,857.53
| Professional | | $1,369.42 | $1,652.60 | $1,857.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.43 / $2,358.36 / $5,003.21
| Professional | | $1,520.43 | $2,358.36 | $5,003.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,348.67 / $2,560.83 / $2,849.89
| Professional | | $2,348.67 | $2,560.83 | $2,849.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.67 / $1,550.15 / $2,748.29
| Professional | | $1,258.67 | $1,550.15 | $2,748.29 |
- 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
- $1,390.55 / $1,808.84 / $4,587.64
| Professional | | $1,390.55 | $1,808.84 | $4,587.64 |