- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,533.21 / $4,916.26 / $10,871.00
| Facility | | $2,533.21 | $4,916.26 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,533.21 / $2,880.19 / $4,888.64
| Professional | | $2,533.21 | $2,880.19 | $4,888.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,300.19 / $3,772.87 / $7,508.44
| Professional | | $2,300.19 | $3,772.87 | $7,508.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,446.75 / $4,448.60 / $5,390.63
| Professional | | $3,446.75 | $4,448.60 | $5,390.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.79 / $3,406.43 / $5,705.96
| Professional | | $2,371.79 | $3,406.43 | $5,705.96 |
- 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
- $1,984.84 / $3,087.75 / $6,321.25
| Professional | | $1,984.84 | $3,087.75 | $6,321.25 |