- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,388.44 / $5,370.32
| Facility | | $1,819.70 | $3,388.44 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $1,949.84
| Professional | | $1,174.90 | $1,445.44 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $2,884.03
| Facility | | $2,137.96 | $2,398.83 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,311.31 / $8,128.31
| Facility | | $1,148.15 | $3,311.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,137.96 / $2,570.40
| Professional | | $2,041.74 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $2,398.83 / $3,235.94
| Professional | | $346.74 | $2,398.83 | $3,235.94 |
- 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
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $3,548.13
| Facility | | $1,778.28 | $1,778.28 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,071.52 / $1,778.28
| Professional | | $741.31 | $1,071.52 | $1,778.28 |