- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,484.19 / $4,806.77 / $10,871.00
| Facility | | $2,484.19 | $4,806.77 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,484.19 / $2,838.61 / $4,713.72
| Professional | | $2,484.19 | $2,838.61 | $4,713.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.36 / $3,708.18 / $7,372.98
| Professional | | $2,150.36 | $3,708.18 | $7,372.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,057.98 / $4,375.39 / $5,310.08
| Professional | | $3,057.98 | $4,375.39 | $5,310.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,324.15 / $3,281.14 / $5,602.73
| Professional | | $2,324.15 | $3,281.14 | $5,602.73 |
- 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
- $1,859.00 / $3,089.04 / $6,416.21
| Professional | | $1,859.00 | $3,089.04 | $6,416.21 |