- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,459.27 / $3,038.00 / $4,387.00
| Facility | | $2,459.27 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.07 / $2,459.27 / $2,459.27
| Professional | | $1,053.07 | $2,459.27 | $2,459.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $6,033.66
| Professional | | $45.00 | $45.00 | $6,033.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.09 / $2,951.07 / $3,471.85
| Professional | | $1,115.09 | $2,951.07 | $3,471.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,312.00 / $2,446.00 / $13,847.00
| Facility | | $2,312.00 | $2,446.00 | $13,847.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.05 / $1,276.02 / $2,349.92
| Professional | | $1,077.05 | $1,276.02 | $2,349.92 |