- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,740.38 / $3,038.00 / $4,387.00
| Facility | | $1,740.38 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.26 / $1,448.05 / $3,823.87
| Professional | | $1,182.26 | $1,448.05 | $3,823.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.02 / $1,842.06 / $2,743.48
| Professional | | $1,309.02 | $1,842.06 | $2,743.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.48 / $867.43 / $1,284.44
| Professional | | $90.48 | $867.43 | $1,284.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.86 / $2,193.42 / $2,867.21
| Professional | | $1,738.86 | $2,193.42 | $2,867.21 |
- 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
- $1,185.44 / $1,554.39 / $2,564.75
| Professional | | $1,185.44 | $1,554.39 | $2,564.75 |