- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.66 / $3,795.48 / $5,080.10
| Facility | | $2,481.66 | $3,795.48 | $5,080.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,218.90 / $2,540.05 / $3,357.54
| Professional | | $2,218.90 | $2,540.05 | $3,357.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.00 / $2,547.42 / $5,379.75
| Professional | | $208.00 | $2,547.42 | $5,379.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,021.31 / $5,638.19 / $6,959.01
| Facility | | $4,021.31 | $5,638.19 | $6,959.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.35 / $3,388.35 / $3,388.35
| Professional | | $3,388.35 | $3,388.35 | $3,388.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.66 / $3,503.52 / $13,868.10
| Facility | | $2,481.66 | $3,503.52 | $13,868.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $14,539.61
| Professional | | $1,226.23 | $1,751.76 | $14,539.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $3,302.07
| Professional | | $1,226.23 | $1,751.76 | $3,302.07 |