- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,984.43 / $4,540.00 / $10,871.00
| Facility | | $1,984.43 | $4,540.00 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,984.43 / $2,302.15 / $3,854.67
| Professional | | $1,984.43 | $2,302.15 | $3,854.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.40 / $3,017.76 / $6,044.46
| Professional | | $1,688.40 | $3,017.76 | $6,044.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,458.41 / $3,536.87 / $4,276.41
| Professional | | $2,458.41 | $3,536.87 | $4,276.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,892.63 / $2,665.48 / $4,572.83
| Professional | | $1,892.63 | $2,665.48 | $4,572.83 |
- 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
- $1,470.00 / $2,432.44 / $5,134.35
| Professional | | $1,470.00 | $2,432.44 | $5,134.35 |