- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,304.67 / $2,304.67 / $3,285.18
| Facility | | $2,304.67 | $2,304.67 | $3,285.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.47 / $2,463.88 / $2,463.88
| Professional | | $884.47 | $2,463.88 | $2,463.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,927.74 / $4,927.74 / $4,927.74
| Facility | | $4,927.74 | $4,927.74 | $4,927.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,536.45 / $2,463.88 / $2,710.27
| Facility | | $1,536.45 | $2,463.88 | $2,710.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,263.53 / $1,516.24
| Professional | | $1,263.53 | $1,263.53 | $1,516.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $78.00
| Professional | | $30.00 | $30.00 | $78.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.30 / $2,527.06 / $4,548.71
| Facility | | $1,895.30 | $2,527.06 | $4,548.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.51 / $1,888.51 / $1,951.76
| Professional | | $1,888.51 | $1,888.51 | $1,951.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $530.67 / $1,453.06
| Professional | | $530.67 | $530.67 | $1,453.06 |