- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,451.80 / $3,159.65 / $4,620.95
| Facility | | $1,451.80 | $3,159.65 | $4,620.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.86 / $1,451.80 / $1,522.61
| Professional | | $1,327.86 | $1,451.80 | $1,522.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,071.46 / $2,478.67 / $3,133.74
| Facility | | $2,071.46 | $2,478.67 | $3,133.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,319.98 / $4,234.97 / $8,149.69
| Facility | | $2,319.98 | $4,234.97 | $8,149.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,124.58 / $2,156.50 / $2,583.73
| Professional | | $2,124.58 | $2,156.50 | $2,583.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,593.43 / $2,390.15 / $3,718.01
| Professional | | $1,593.43 | $2,390.15 | $3,718.01 |
- 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
- $2,301.62 / $2,301.62 / $2,301.62
| Professional | | $2,301.62 | $2,301.62 | $2,301.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $2,407.85 / $2,602.61
| Professional | | $30.00 | $2,407.85 | $2,602.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $743.60 / $3,540.96 / $3,540.96
| Facility | | $743.60 | $3,540.96 | $3,540.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.60 / $1,062.29 / $1,770.48
| Professional | | $743.60 | $1,062.29 | $1,770.48 |