- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,585.52 / $3,038.00 / $4,387.00
| Facility | | $1,585.52 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,585.52 / $1,585.52 / $3,144.38
| Professional | | $1,585.52 | $1,585.52 | $3,144.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.63 / $1,859.64 / $2,851.24
| Professional | | $1,601.63 | $1,859.64 | $2,851.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.39 / $805.47 / $1,227.20
| Professional | | $107.39 | $805.47 | $1,227.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.53 / $2,419.41 / $2,943.10
| Professional | | $1,707.53 | $2,419.41 | $2,943.10 |
- 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
- $1,268.51 / $1,545.60 / $2,767.67
| Professional | | $1,268.51 | $1,545.60 | $2,767.67 |