- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,388.41 / $3,038.00 / $4,387.00
| Facility | | $2,388.41 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.41 / $2,388.41 / $5,203.41
| Professional | | $1,667.41 | $2,388.41 | $5,203.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.65 / $2,510.48 / $3,749.59
| Professional | | $1,775.65 | $2,510.48 | $3,749.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.98 / $1,179.21 / $1,726.85
| Professional | | $135.98 | $1,179.21 | $1,726.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,367.21 / $3,008.12 / $3,826.73
| Professional | | $2,367.21 | $3,008.12 | $3,826.73 |
- 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
- $1,629.76 / $2,093.60 / $3,199.83
| Professional | | $1,629.76 | $2,093.60 | $3,199.83 |