- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,495.05 / $5,122.93 / $10,871.00
| Facility | | $2,495.05 | $5,122.93 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.05 / $3,014.04 / $5,122.93
| Professional | | $2,495.05 | $3,014.04 | $5,122.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.46 / $3,919.46 / $7,844.32
| Professional | | $2,012.46 | $3,919.46 | $7,844.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,244.80 / $4,644.00 / $5,635.05
| Professional | | $3,244.80 | $4,644.00 | $5,635.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,477.17 / $3,434.54 / $5,657.22
| Professional | | $2,477.17 | $3,434.54 | $5,657.22 |
- 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
- $1,830.47 / $3,204.03 / $6,579.55
| Professional | | $1,830.47 | $3,204.03 | $6,579.55 |