- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,576.88 / $6,788.76 / $9,586.02
| Facility | | $3,576.88 | $6,788.76 | $9,586.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,294.42 / $2,721.91 / $3,140.67
| Professional | | $2,294.42 | $2,721.91 | $3,140.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,082.86 / $4,885.47 / $6,176.64
| Facility | | $4,082.86 | $4,885.47 | $6,176.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,427.43 / $8,347.20 / $16,064.10
| Facility | | $4,427.43 | $8,347.20 | $16,064.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.33 / $4,187.56 / $4,623.91
| Professional | | $3,859.33 | $4,187.56 | $4,623.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,140.67 / $4,711.00 / $7,328.22
| Professional | | $3,140.67 | $4,711.00 | $7,328.22 |
- 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
- $30.00 / $30.00 / $5,129.76
| Professional | | $30.00 | $30.00 | $5,129.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.64 / $2,093.78 / $3,489.63
| Professional | | $1,465.64 | $2,093.78 | $3,489.63 |