- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,547.44 / $4,754.58 / $10,871.00
| Facility | | $2,547.44 | $4,754.58 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,547.44 / $2,851.90 / $4,772.92
| Professional | | $2,547.44 | $2,851.90 | $4,772.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.50 / $3,729.33 / $7,446.62
| Professional | | $2,096.50 | $3,729.33 | $7,446.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,013.49 / $4,307.37 / $5,237.82
| Professional | | $3,013.49 | $4,307.37 | $5,237.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,246.77 / $3,284.39 / $5,704.03
| Professional | | $2,246.77 | $3,284.39 | $5,704.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,423.00 / $3,961.00 / $9,513.00
| Facility | | $1,423.00 | $3,961.00 | $9,513.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.40 / $2,924.17 / $6,047.65
| Professional | | $1,700.40 | $2,924.17 | $6,047.65 |