- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,601.52 / $3,038.00 / $4,387.00
| Facility | | $2,601.52 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,601.52 / $2,601.52 / $5,486.35
| Professional | | $2,601.52 | $2,601.52 | $5,486.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,295.42 / $2,685.45 / $3,419.20
| Professional | | $2,295.42 | $2,685.45 | $3,419.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.11 / $1,221.67 / $1,755.76
| Professional | | $107.11 | $1,221.67 | $1,755.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,381.58 / $3,260.38 / $4,334.10
| Professional | | $2,381.58 | $3,260.38 | $4,334.10 |
- 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
- $1,794.17 / $1,935.85 / $3,236.64
| Professional | | $1,794.17 | $1,935.85 | $3,236.64 |