- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.09 / $2,164.46 / $3,487.19
| Facility | | $1,336.09 | $2,164.46 | $3,487.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.07 / $1,095.58 / $1,202.48
| Professional | | $1,002.07 | $1,095.58 | $1,202.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,563.22 / $1,870.52 / $2,364.87
| Facility | | $1,563.22 | $1,870.52 | $2,364.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.52 / $3,195.93 / $6,151.35
| Facility | | $1,500.52 | $3,195.93 | $6,151.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.31 / $1,627.23 / $1,949.60
| Professional | | $1,603.31 | $1,627.23 | $1,949.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,870.53 / $2,805.79
| Professional | | $1,336.09 | $1,870.53 | $2,805.79 |
- 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
- $1,736.92 / $1,736.92 / $1,736.92
| Professional | | $1,736.92 | $1,736.92 | $1,736.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,817.08 / $1,817.08 / $2,004.14
| Professional | | $1,817.08 | $1,817.08 | $2,004.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $801.65 / $1,336.09
| Professional | | $561.16 | $801.65 | $1,336.09 |