- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,529.13 / $5,982.00 / $11,298.00
| Facility | | $1,529.13 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.22 / $2,093.88 / $2,598.85
| Professional | | $1,346.22 | $2,093.88 | $2,598.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.05 / $2,794.21 / $6,886.50
| Professional | | $1,473.05 | $2,794.21 | $6,886.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,302.24 / $3,600.01 / $4,006.36
| Professional | | $3,302.24 | $3,600.01 | $4,006.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.31 / $2,207.77 / $4,355.62
| Professional | | $1,751.31 | $2,207.77 | $4,355.62 |
- 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
- $1,748.62 / $2,414.60 / $5,744.91
| Professional | | $1,748.62 | $2,414.60 | $5,744.91 |