- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,632.65 / $3,038.00 / $4,387.00
| Facility | | $1,632.65 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.65 / $1,632.65 / $3,259.07
| Professional | | $1,632.65 | $1,632.65 | $3,259.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.55 / $1,934.37 / $2,957.57
| Professional | | $1,648.55 | $1,934.37 | $2,957.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.43 / $830.17 / $1,256.92
| Professional | | $108.43 | $830.17 | $1,256.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,774.11 / $2,482.75 / $3,019.78
| Professional | | $1,774.11 | $2,482.75 | $3,019.78 |
- 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
- $1,308.11 / $1,609.60 / $2,854.08
| Professional | | $1,308.11 | $1,609.60 | $2,854.08 |