- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,719.14 / $5,982.00 / $11,298.00
| Facility | | $2,719.14 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.62 / $2,693.30 / $2,887.54
| Professional | | $2,352.62 | $2,693.30 | $2,887.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,295.34 / $3,688.04 / $8,045.62
| Professional | | $2,295.34 | $3,688.04 | $8,045.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,604.51 / $3,976.46 / $4,425.31
| Professional | | $3,604.51 | $3,976.46 | $4,425.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,944.56 / $2,461.81 / $4,627.68
| Professional | | $1,944.56 | $2,461.81 | $4,627.68 |
- 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
- $2,146.58 / $2,644.09 / $6,711.53
| Professional | | $2,146.58 | $2,644.09 | $6,711.53 |