- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,842.51 / $4,540.00 / $10,871.00
| Facility | | $1,842.51 | $4,540.00 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.51 / $2,138.28 / $3,615.83
| Professional | | $1,842.51 | $2,138.28 | $3,615.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.41 / $2,803.78 / $5,575.86
| Professional | | $1,578.41 | $2,803.78 | $5,575.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,304.33 / $3,303.80 / $4,003.93
| Professional | | $2,304.33 | $3,303.80 | $4,003.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.95 / $2,507.57 / $4,238.63
| Professional | | $1,758.95 | $2,507.57 | $4,238.63 |
- 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
- $1,441.57 / $2,270.40 / $4,972.80
| Professional | | $1,441.57 | $2,270.40 | $4,972.80 |