- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,543.44 / $3,038.00 / $4,387.00
| Facility | | $2,543.44 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,289.75 / $2,543.44 / $4,082.43
| Professional | | $2,289.75 | $2,543.44 | $4,082.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.83 / $2,555.73 / $3,889.66
| Professional | | $2,161.83 | $2,555.73 | $3,889.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.29 / $1,313.74 / $1,721.35
| Professional | | $109.29 | $1,313.74 | $1,721.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.69 / $3,506.59 / $4,125.39
| Professional | | $2,323.69 | $3,506.59 | $4,125.39 |
- 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
- $1,509.46 / $2,084.81 / $3,747.59
| Professional | | $1,509.46 | $2,084.81 | $3,747.59 |