- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,113.23 / $3,258.70 / $4,952.46
| Facility | | $2,113.23 | $3,258.70 | $4,952.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.23 / $2,137.48 / $3,068.66
| Professional | | $2,113.23 | $2,137.48 | $3,068.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.08 / $4,221.72 / $23,884.35
| Facility | | $1,518.08 | $4,221.72 | $23,884.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,116.32
| Facility | | $2,116.32 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,116.32
| Professional | | $2,116.32 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.25 / $2,158.65 / $3,107.05
| Professional | | $926.25 | $2,158.65 | $3,107.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,751.22 / $2,751.22 / $2,751.22
| Professional | | $2,751.22 | $2,751.22 | $2,751.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,245.42
| Professional | | $2,116.32 | $2,116.32 | $2,245.42 |