- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,038.00 / $3,361.04 / $4,387.00
| Facility | | $3,038.00 | $3,361.04 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,361.04 / $3,361.04 / $6,993.01
| Professional | | $3,361.04 | $3,361.04 | $6,993.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,093.44 / $3,322.14 / $4,353.47
| Professional | | $3,093.44 | $3,322.14 | $4,353.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $1,554.66 / $2,239.80
| Professional | | $134.83 | $1,554.66 | $2,239.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,026.47 / $4,197.10 / $5,328.37
| Professional | | $3,026.47 | $4,197.10 | $5,328.37 |
- 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
- $2,264.79 / $2,656.48 / $4,941.35
| Professional | | $2,264.79 | $2,656.48 | $4,941.35 |