- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,394.07 / $5,210.39 / $7,620.16
| Facility | | $2,394.07 | $5,210.39 | $7,620.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,248.09 / $2,394.07 / $2,627.64
| Professional | | $2,248.09 | $2,394.07 | $2,627.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,415.93 / $4,087.44 / $5,167.68
| Facility | | $3,415.93 | $4,087.44 | $5,167.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,825.58 / $6,983.68 / $13,440.36
| Facility | | $3,825.58 | $6,983.68 | $13,440.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,503.52 / $3,556.09 / $4,260.59
| Professional | | $3,503.52 | $3,556.09 | $4,260.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.00 / $3,211.56 / $5,284.48
| Professional | | $125.00 | $3,211.56 | $5,284.48 |
- 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 / $3,970.66 / $4,291.81
| Professional | | $30.00 | $3,970.66 | $4,291.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $2,919.60
| Professional | | $1,226.23 | $1,751.76 | $2,919.60 |