- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,311.31 / $5,754.40
| Facility | | $1,949.84 | $3,311.31 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $2,089.30
| Professional | | $1,258.93 | $1,548.82 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,570.40 / $3,090.30
| Facility | | $2,290.87 | $2,570.40 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,981.07 / $8,709.64
| Facility | | $1,230.27 | $3,981.07 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,290.87 / $2,754.23
| Professional | | $2,187.76 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $2,570.40 / $3,548.13
| Professional | | $346.74 | $2,570.40 | $3,548.13 |
- 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
- $1,905.46 / $1,905.46 / $3,801.89
| Facility | | $1,905.46 | $1,905.46 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $1,905.46
| Professional | | $794.33 | $1,148.15 | $1,905.46 |