- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,774.02 / $2,774.02 / $3,996.25
| Facility | | $2,774.02 | $2,774.02 | $3,996.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.91 / $1,444.80 / $1,444.80
| Professional | | $1,075.91 | $1,444.80 | $1,444.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,198.86 / $3,196.99 / $5,994.36
| Facility | | $1,198.86 | $3,196.99 | $5,994.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,849.34 / $2,997.19 / $3,296.91
| Facility | | $1,849.34 | $2,997.19 | $3,296.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.02 / $1,537.02 / $1,844.42
| Professional | | $1,537.02 | $1,537.02 | $1,844.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $2,997.19
| Professional | | $30.00 | $30.00 | $2,997.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,305.53 / $3,074.04 / $5,533.27
| Facility | | $2,305.53 | $3,074.04 | $5,533.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,296.96 / $2,296.96 / $2,374.14
| Professional | | $2,296.96 | $2,296.96 | $2,374.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.54 / $645.54 / $2,459.23
| Professional | | $645.54 | $645.54 | $2,459.23 |