- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,535.31 / $5,982.00 / $11,298.00
| Facility | | $1,535.31 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.31 / $2,032.76 / $3,191.43
| Professional | | $1,535.31 | $2,032.76 | $3,191.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,678.08 / $2,849.72 / $6,008.39
| Professional | | $1,678.08 | $2,849.72 | $6,008.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.63 / $2,901.75 / $3,460.49
| Professional | | $2,139.63 | $2,901.75 | $3,460.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.03 / $1,974.86 / $3,757.77
| Professional | | $1,540.03 | $1,974.86 | $3,757.77 |
- 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
- $1,391.06 / $1,976.27 / $4,280.96
| Professional | | $1,391.06 | $1,976.27 | $4,280.96 |