- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,539.08 / $3,038.00 / $4,387.00
| Facility | | $2,539.08 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,539.08 / $2,539.08 / $5,597.54
| Professional | | $2,539.08 | $2,539.08 | $5,597.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,357.15 / $2,741.93 / $3,084.67
| Professional | | $2,357.15 | $2,741.93 | $3,084.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.11 / $1,242.00 / $1,765.37
| Professional | | $107.11 | $1,242.00 | $1,765.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,425.53 / $3,335.16 / $4,323.62
| Professional | | $2,425.53 | $3,335.16 | $4,323.62 |
- 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
- $1,747.26 / $2,190.77 / $3,945.60
| Professional | | $1,747.26 | $2,190.77 | $3,945.60 |