- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,868.14 / $5,695.00 / $10,871.00
| Facility | | $3,868.14 | $5,695.00 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,868.14 / $4,507.41 / $7,212.85
| Professional | | $3,868.14 | $4,507.41 | $7,212.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.52 / $5,663.02 / $11,281.59
| Professional | | $2,823.52 | $5,663.02 | $11,281.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.74 / $6,515.81 / $7,937.97
| Professional | | $4,570.74 | $6,515.81 | $7,937.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,421.45 / $4,859.39 / $9,024.28
| Professional | | $3,421.45 | $4,859.39 | $9,024.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,627.00 / $6,590.00 / $10,536.00
| Facility | | $1,627.00 | $6,590.00 | $10,536.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,496.42 / $4,564.25 / $10,053.20
| Professional | | $2,496.42 | $4,564.25 | $10,053.20 |