- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,257.67 / $4,405.20 / $7,185.98
| Facility | | $2,257.67 | $4,405.20 | $7,185.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.94 / $2,257.67 / $2,477.92
| Professional | | $2,064.94 | $2,257.67 | $2,477.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,221.30 / $3,854.55 / $4,873.25
| Facility | | $3,221.30 | $3,854.55 | $4,873.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,753.25 / $2,753.25 / $4,184.93
| Professional | | $2,753.25 | $2,753.25 | $4,184.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,493.09 / $6,729.77 / $12,674.97
| Facility | | $3,493.09 | $6,729.77 | $12,674.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,303.90 / $3,353.83 / $4,018.27
| Professional | | $3,303.90 | $3,353.83 | $4,018.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,753.25 / $3,854.55 / $5,781.83
| Professional | | $2,753.25 | $3,854.55 | $5,781.83 |
- 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
- $3,744.42 / $3,744.42 / $4,129.88
| Professional | | $3,744.42 | $3,744.42 | $4,129.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.36 / $1,651.95 / $2,753.25
| Professional | | $1,156.36 | $1,651.95 | $2,753.25 |