- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,230.41 / $5,982.00 / $11,298.00
| Facility | | $2,230.41 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,815.53 / $2,230.41 / $3,686.59
| Professional | | $1,815.53 | $2,230.41 | $3,686.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,108.94 / $3,509.28 / $10,858.52
| Professional | | $2,108.94 | $3,509.28 | $10,858.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,740.72 / $3,411.43 / $4,175.80
| Professional | | $2,740.72 | $3,411.43 | $4,175.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,927.81 / $2,440.61 / $5,158.72
| Professional | | $1,927.81 | $2,440.61 | $5,158.72 |
- 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
- $1,931.68 / $2,513.42 / $6,971.22
| Professional | | $1,931.68 | $2,513.42 | $6,971.22 |