- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,000.52 / $5,860.41 / $10,871.00
| Facility | | $3,000.52 | $5,860.41 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,000.52 / $3,515.51 / $5,920.16
| Professional | | $3,000.52 | $3,515.51 | $5,920.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,475.92 / $4,576.16 / $9,093.93
| Professional | | $2,475.92 | $4,576.16 | $9,093.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,799.60 / $5,456.47 / $6,605.48
| Professional | | $3,799.60 | $5,456.47 | $6,605.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.01 / $4,071.54 / $6,545.16
| Professional | | $2,884.01 | $4,071.54 | $6,545.16 |
- 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
- $2,301.82 / $3,847.14 / $8,380.40
| Professional | | $2,301.82 | $3,847.14 | $8,380.40 |