- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,330.52 / $5,982.00 / $11,298.00
| Facility | | $1,330.52 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.52 / $1,771.37 / $2,784.02
| Professional | | $1,330.52 | $1,771.37 | $2,784.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.37 / $2,491.94 / $5,247.73
| Professional | | $1,458.37 | $2,491.94 | $5,247.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,859.54 / $2,522.54 / $3,007.78
| Professional | | $1,859.54 | $2,522.54 | $3,007.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.74 / $1,741.54 / $3,248.60
| Professional | | $1,345.74 | $1,741.54 | $3,248.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,846.00 / $7,273.00 / $10,536.00
| Facility | | $1,846.00 | $7,273.00 | $10,536.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.53 / $1,654.33 / $3,740.87
| Professional | | $1,183.53 | $1,654.33 | $3,740.87 |