- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,550.19 / $4,080.32 / $6,493.68
| Facility | | $2,550.19 | $4,080.32 | $6,493.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.86 / $1,635.86 / $3,483.20
| Professional | | $1,635.86 | $1,635.86 | $3,483.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,910.96 / $3,483.20 / $4,403.76
| Facility | | $2,910.96 | $3,483.20 | $4,403.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,738.54 / $6,181.73 / $11,453.94
| Facility | | $1,738.54 | $6,181.73 | $11,453.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,736.80 / $3,032.25 / $3,790.31
| Professional | | $2,736.80 | $3,032.25 | $3,790.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.40 / $3,358.80 / $4,453.64
| Professional | | $345.40 | $3,358.80 | $4,453.64 |
- 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
- $1,244.00 / $1,706.77 / $2,488.00
| Professional | | $1,244.00 | $1,706.77 | $2,488.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.96 / $1,492.80 / $2,488.00
| Professional | | $1,044.96 | $1,492.80 | $2,488.00 |