- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,979.51 / $5,982.00 / $11,298.00
| Facility | | $2,979.51 | $5,982.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,641.64 / $3,320.65 / $5,620.73
| Professional | | $2,641.64 | $3,320.65 | $5,620.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,779.98 / $5,399.63 / $16,334.10
| Professional | | $2,779.98 | $5,399.63 | $16,334.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,066.72 / $5,121.89 / $6,226.83
| Professional | | $4,066.72 | $5,121.89 | $6,226.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,907.44 / $3,674.98 / $6,481.80
| Professional | | $2,907.44 | $3,674.98 | $6,481.80 |
- 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
- $2,885.40 / $4,125.89 / $10,414.84
| Professional | | $2,885.40 | $4,125.89 | $10,414.84 |