- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,324.73 / $5,982.00 / $10,871.00
| Facility | | $3,324.73 | $5,982.00 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,324.73 / $3,799.44 / $6,432.74
| Professional | | $3,324.73 | $3,799.44 | $6,432.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,478.71 / $4,937.64 / $9,909.82
| Professional | | $2,478.71 | $4,937.64 | $9,909.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,010.62 / $5,727.05 / $6,968.82
| Professional | | $4,010.62 | $5,727.05 | $6,968.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,995.87 / $4,311.64 / $7,597.42
| Professional | | $2,995.87 | $4,311.64 | $7,597.42 |
- 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
- $2,275.44 / $3,989.34 / $8,236.68
| Professional | | $2,275.44 | $3,989.34 | $8,236.68 |