- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,245.63 / $2,430.50 / $3,964.75
| Facility | | $1,245.63 | $2,430.50 | $3,964.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.30 / $1,245.63 / $1,367.15
| Professional | | $1,139.30 | $1,245.63 | $1,367.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,777.30 / $2,126.67 / $2,688.73
| Facility | | $1,777.30 | $2,126.67 | $2,688.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,927.26 / $3,633.60 / $6,992.68
| Facility | | $1,927.26 | $3,633.60 | $6,992.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.87 / $1,850.06 / $2,216.58
| Professional | | $1,822.87 | $1,850.06 | $2,216.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.06 / $2,126.67 / $3,190.03
| Professional | | $1,519.06 | $2,126.67 | $3,190.03 |
- 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 / $2,233.02
| Professional | | $30.00 | $30.00 | $2,233.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.01 / $911.44 / $1,519.06
| Professional | | $638.01 | $911.44 | $1,519.06 |