- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,754.40 / $8,912.51
| Facility | | $3,162.28 | $5,754.40 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,454.71 / $2,818.38
| Professional | | $1,513.56 | $2,454.71 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,073.80 / $4,897.79
| Facility | | $3,630.78 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Professional | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,754.40 / $13,803.84
| Facility | | $1,949.84 | $5,754.40 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,630.78 / $4,365.16
| Professional | | $3,467.37 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $4,073.80 / $5,495.41
| Professional | | $346.74 | $4,073.80 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $6,025.60
| Facility | | $3,019.95 | $3,019.95 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $3,019.95
| Professional | | $1,258.93 | $1,819.70 | $3,019.95 |