- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,344.23 / $7,762.47
| Facility | | $794.33 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,951.21 / $4,073.80
| Professional | | $1,905.46 | $2,951.21 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,398.83 / $2,818.38
| Facility | | $1,047.13 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $7,413.10
| Professional | | $120.23 | $199.53 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,290.87 / $4,786.30
| Facility | | $891.25 | $2,290.87 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,897.79 / $7,762.47
| Professional | | $3,467.37 | $4,897.79 | $7,762.47 |