- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,133.67 / $3,374.53 / $5,823.69
| Facility | | $2,133.67 | $3,374.53 | $5,823.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,907.76 / $2,183.88 / $2,886.74
| Professional | | $1,907.76 | $2,183.88 | $2,886.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.00 / $2,240.36 / $4,445.97
| Professional | | $304.00 | $2,240.36 | $4,445.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,457.45 / $4,847.60 / $5,983.22
| Facility | | $3,457.45 | $4,847.60 | $5,983.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.19 / $2,645.19 / $2,645.19
| Professional | | $2,645.19 | $2,645.19 | $2,645.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,133.67 / $3,012.25 / $11,923.50
| Facility | | $2,133.67 | $3,012.25 | $11,923.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,506.13 / $12,500.85
| Professional | | $1,054.29 | $1,506.13 | $12,500.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,506.13 / $2,839.05
| Professional | | $1,054.29 | $1,506.13 | $2,839.05 |