- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,565.61 / $3,000.00 / $8,108.32
| Facility | | $2,565.61 | $3,000.00 | $8,108.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.98 / $1,242.47 / $2,441.96
| Professional | | $910.98 | $1,242.47 | $2,441.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.14 / $1,383.57 / $2,071.92
| Professional | | $893.14 | $1,383.57 | $2,071.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,004.61 / $2,608.39 / $3,705.00
| Facility | | $1,004.61 | $2,608.39 | $3,705.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.06 / $1,752.06 / $3,054.74
| Professional | | $1,318.06 | $1,752.06 | $3,054.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.72 / $1,458.11 / $2,062.15
| Professional | | $1,211.72 | $1,458.11 | $2,062.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.03 / $1,795.34 / $3,107.52
| Professional | | $978.03 | $1,795.34 | $3,107.52 |