- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,337.00 / $2,337.00 / $19,069.90
| Facility | | $2,337.00 | $2,337.00 | $19,069.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.00 / $2,337.00 / $2,430.48
| Professional | | $2,337.00 | $2,337.00 | $2,430.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,492.80 / $2,804.40 / $2,804.40
| Professional | | $2,492.80 | $2,804.40 | $2,804.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,063.50 / $5,266.04 / $11,327.48
| Facility | | $5,063.50 | $5,266.04 | $11,327.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.09 / $9,857.06 / $24,278.62
| Professional | | $1,878.09 | $9,857.06 | $24,278.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,583.40 / $6,333.89 / $6,333.89
| Professional | | $3,583.40 | $6,333.89 | $6,333.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.72 / $1,869.60 / $4,969.91
| Professional | | $1,308.72 | $1,869.60 | $4,969.91 |