- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,310.06 / $3,038.00 / $4,387.00
| Facility | | $1,310.06 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.06 / $1,310.06 / $2,268.83
| Professional | | $1,310.06 | $1,310.06 | $2,268.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.78 / $1,870.13 / $3,738.84
| Professional | | $1,550.78 | $1,870.13 | $3,738.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.43 / $766.57 / $1,217.78
| Professional | | $108.43 | $766.57 | $1,217.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.97 / $2,245.73 / $3,599.72
| Professional | | $1,707.97 | $2,245.73 | $3,599.72 |
- 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
- $1,244.76 / $1,711.55 / $2,715.84
| Professional | | $1,244.76 | $1,711.55 | $2,715.84 |