- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.56 / $3,038.00 / $4,387.00
| Facility | | $1,650.56 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.56 / $1,650.56 / $3,279.22
| Professional | | $1,650.56 | $1,650.56 | $3,279.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.54 / $1,561.60 / $3,192.68
| Professional | | $1,428.54 | $1,561.60 | $3,192.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.01 / $784.80 / $1,127.21
| Professional | | $61.01 | $784.80 | $1,127.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.76 / $2,294.89 / $3,675.68
| Professional | | $1,457.76 | $2,294.89 | $3,675.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,292.00 / $4,455.00 / $13,847.00
| Facility | | $1,292.00 | $4,455.00 | $13,847.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.66 / $1,226.59 / $2,305.44
| Professional | | $1,056.66 | $1,226.59 | $2,305.44 |