- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,471.94 / $5,982.00 / $11,298.00
| Facility | | $1,471.94 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.94 / $1,951.02 / $3,056.01
| Professional | | $1,471.94 | $1,951.02 | $3,056.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.33 / $2,740.13 / $5,769.81
| Professional | | $1,611.33 | $2,740.13 | $5,769.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,046.83 / $2,775.26 / $3,310.91
| Professional | | $2,046.83 | $2,775.26 | $3,310.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.81 / $2,003.64 / $3,339.84
| Professional | | $1,479.81 | $2,003.64 | $3,339.84 |
- 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
- $1,302.57 / $1,900.48 / $4,113.56
| Professional | | $1,302.57 | $1,900.48 | $4,113.56 |