- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,351.53 / $3,038.00 / $4,387.00
| Facility | | $2,351.53 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.06 / $2,351.53 / $7,897.68
| Professional | | $1,740.06 | $2,351.53 | $7,897.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,047.18 / $2,167.48 / $2,857.44
| Professional | | $2,047.18 | $2,167.48 | $2,857.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.27 / $1,029.23 / $1,467.74
| Professional | | $89.27 | $1,029.23 | $1,467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.25 / $2,949.86 / $3,470.42
| Professional | | $1,991.25 | $2,949.86 | $3,470.42 |
- 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
- $1,477.41 / $1,802.80 / $3,223.44
| Professional | | $1,477.41 | $1,802.80 | $3,223.44 |