- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $2,033.27 / $7,727.00
| Facility | | $1,017.00 | $2,033.27 | $7,727.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,033.27 / $2,033.27 / $2,033.27
| Professional | | $2,033.27 | $2,033.27 | $2,033.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,244.52 / $2,253.66 / $2,575.02
| Professional | | $2,244.52 | $2,253.66 | $2,575.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.38 / $2,879.10 / $6,336.61
| Professional | | $2,056.38 | $2,879.10 | $6,336.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,200.01 / $4,562.43 / $4,562.43
| Professional | | $2,200.01 | $4,562.43 | $4,562.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,261.00 / $4,165.00 / $26,408.00
| Facility | | $3,261.00 | $4,165.00 | $26,408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.68 / $3,021.38 / $5,272.27
| Professional | | $1,933.68 | $3,021.38 | $5,272.27 |