- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,505.62 / $3,038.00 / $4,387.00
| Facility | | $2,505.62 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,505.62 / $2,505.62 / $12,347.50
| Professional | | $2,505.62 | $2,505.62 | $12,347.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.88 / $5,876.70 / $6,855.53
| Professional | | $2,191.88 | $5,876.70 | $6,855.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.21 / $2,727.41 / $3,924.05
| Professional | | $219.21 | $2,727.41 | $3,924.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,314.92 / $8,033.77 / $9,451.49
| Professional | | $5,314.92 | $8,033.77 | $9,451.49 |
- 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
- $1,804.64 / $4,418.81 / $8,815.68
| Professional | | $1,804.64 | $4,418.81 | $8,815.68 |