- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.25 / $3,038.00 / $4,387.00
| Facility | | $2,756.25 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,756.25 / $2,756.25 / $5,015.42
| Professional | | $2,756.25 | $2,756.25 | $5,015.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.94 / $2,447.14 / $4,794.09
| Professional | | $2,326.94 | $2,447.14 | $4,794.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.43 / $1,118.06 / $1,602.83
| Professional | | $108.43 | $1,118.06 | $1,602.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.84 / $3,323.78 / $5,051.80
| Professional | | $2,171.84 | $3,323.78 | $5,051.80 |
- 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
- $1,634.49 / $2,002.81 / $3,566.16
| Professional | | $1,634.49 | $2,002.81 | $3,566.16 |