- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,527.19 / $4,894.79 / $10,871.00
| Facility | | $2,527.19 | $4,894.79 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.19 / $2,867.49 / $4,894.79
| Professional | | $2,527.19 | $2,867.49 | $4,894.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.26 / $3,755.86 / $7,476.22
| Professional | | $2,280.26 | $3,755.86 | $7,476.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,088.47 / $4,429.29 / $5,367.06
| Professional | | $3,088.47 | $4,429.29 | $5,367.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,361.80 / $3,324.18 / $5,681.93
| Professional | | $2,361.80 | $3,324.18 | $5,681.93 |
- 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
- $1,955.06 / $3,128.17 / $6,675.65
| Professional | | $1,955.06 | $3,128.17 | $6,675.65 |