- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,010.76 / $3,038.00 / $4,387.00
| Facility | | $3,010.76 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,010.76 / $3,010.76 / $5,763.58
| Professional | | $3,010.76 | $3,010.76 | $5,763.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,621.78 / $2,823.38 / $3,590.13
| Professional | | $2,621.78 | $2,823.38 | $3,590.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.43 / $1,269.50 / $1,848.27
| Professional | | $108.43 | $1,269.50 | $1,848.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,497.76 / $3,447.05 / $4,371.00
| Professional | | $2,497.76 | $3,447.05 | $4,371.00 |
- 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
- $1,864.83 / $2,223.06 / $4,068.71
| Professional | | $1,864.83 | $2,223.06 | $4,068.71 |