- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,375.41 / $3,038.00 / $4,387.00
| Facility | | $2,375.41 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,375.41 / $2,375.41 / $4,613.06
| Professional | | $2,375.41 | $2,375.41 | $4,613.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.56 / $2,177.71 / $2,539.85
| Professional | | $2,068.56 | $2,177.71 | $2,539.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.51 / $1,027.30 / $1,497.92
| Professional | | $93.51 | $1,027.30 | $1,497.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.67 / $2,999.04 / $3,528.28
| Professional | | $1,981.67 | $2,999.04 | $3,528.28 |
- 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
- $1,489.29 / $1,895.52 / $3,249.35
| Professional | | $1,489.29 | $1,895.52 | $3,249.35 |