- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.31 / $3,675.00 / $8,386.71
| Facility | | $2,416.31 | $3,675.00 | $8,386.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.75 / $2,416.31 / $2,572.50
| Professional | | $1,947.75 | $2,416.31 | $2,572.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,622.40 / $5,393.06 / $9,095.62
| Facility | | $1,622.40 | $5,393.06 | $9,095.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,874.25 / $3,482.44 / $4,589.47
| Professional | | $1,874.25 | $3,482.44 | $4,589.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,388.75 / $11,820.20 / $21,092.37
| Facility | | $2,388.75 | $11,820.20 | $21,092.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,226.25 / $6,695.85 / $9,077.25
| Professional | | $4,226.25 | $6,695.85 | $9,077.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $2,205.00 / $6,449.26
| Professional | | $1,543.50 | $2,205.00 | $6,449.26 |