- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,943.32 / $3,038.00 / $4,387.00
| Facility | | $1,943.32 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.32 / $1,943.32 / $3,363.19
| Professional | | $1,943.32 | $1,943.32 | $3,363.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.03 / $1,014.91 / $1,442.26
| Professional | | $86.03 | $1,014.91 | $1,442.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,999.51 / $2,792.62 / $4,302.91
| Professional | | $1,999.51 | $2,792.62 | $4,302.91 |
- 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
- $1,415.76 / $1,716.72 / $3,147.85
| Professional | | $1,415.76 | $1,716.72 | $3,147.85 |