- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.48 / $5,982.00 / $11,298.00
| Facility | | $1,116.48 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.48 / $1,490.25 / $2,329.38
| Professional | | $1,116.48 | $1,490.25 | $2,329.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.27 / $2,095.50 / $4,405.91
| Professional | | $1,227.27 | $2,095.50 | $4,405.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.81 / $2,126.50 / $2,533.16
| Professional | | $1,565.81 | $2,126.50 | $2,533.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.78 / $1,509.47 / $2,998.28
| Professional | | $1,126.78 | $1,509.47 | $2,998.28 |
- 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
- $1,010.51 / $1,527.73 / $3,159.62
| Professional | | $1,010.51 | $1,527.73 | $3,159.62 |