- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $6,570.86 / $6,570.86
| Facility | | $100.00 | $6,570.86 | $6,570.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.77 / $1,906.32 / $2,314.71
| Professional | | $1,812.77 | $1,906.32 | $2,314.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,302.10 / $7,096.40 / $13,494.06
| Facility | | $3,302.10 | $7,096.40 | $13,494.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.33 / $3,136.17 / $5,017.31
| Professional | | $1,748.33 | $3,136.17 | $5,017.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,749.23 / $3,320.50 / $5,410.26
| Professional | | $1,749.23 | $3,320.50 | $5,410.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.47 / $3,462.14 / $6,177.54
| Professional | | $2,001.47 | $3,462.14 | $6,177.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $451.00 / $3,360.00 / $7,448.00
| Facility | | $451.00 | $3,360.00 | $7,448.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.34 / $2,862.86 / $5,394.66
| Professional | | $2,091.34 | $2,862.86 | $5,394.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.12 / $1,748.54 / $2,570.36
| Professional | | $1,457.12 | $1,748.54 | $2,570.36 |