- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,600.38 / $3,038.00 / $4,387.00
| Facility | | $2,600.38 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,600.38 / $2,600.38 / $5,086.58
| Professional | | $2,600.38 | $2,600.38 | $5,086.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,257.23 / $2,405.78 / $3,173.55
| Professional | | $2,257.23 | $2,405.78 | $3,173.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.43 / $1,120.31 / $1,602.67
| Professional | | $108.43 | $1,120.31 | $1,602.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,211.44 / $3,277.68 / $3,856.09
| Professional | | $2,211.44 | $3,277.68 | $3,856.09 |
- 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
- $1,640.10 / $1,969.74 / $3,578.39
| Professional | | $1,640.10 | $1,969.74 | $3,578.39 |