- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,462.07 / $5,695.00 / $10,871.00
| Facility | | $2,462.07 | $5,695.00 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.24 / $2,462.07 / $3,493.83
| Professional | | $1,938.24 | $2,462.07 | $3,493.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,338.53 / $3,684.60 / $8,946.08
| Professional | | $2,338.53 | $3,684.60 | $8,946.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,359.98 / $3,250.71 / $4,191.85
| Professional | | $2,359.98 | $3,250.71 | $4,191.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,174.15 / $2,852.10 / $5,878.97
| Professional | | $2,174.15 | $2,852.10 | $5,878.97 |
- 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
- $1,755.04 / $3,325.01 / $6,188.27
| Professional | | $1,755.04 | $3,325.01 | $6,188.27 |