- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,741.78 / $1,741.78 / $1,741.78
| Facility | | $1,741.78 | $1,741.78 | $1,741.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,741.78 / $1,741.78
| Professional | | $1,000.00 | $1,741.78 | $1,741.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,990.58 / $2,756.50 / $4,901.79
| Facility | | $1,990.58 | $2,756.50 | $4,901.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.82 / $141.93 / $170.30
| Professional | | $134.82 | $141.93 | $170.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.61 / $4,421.45 / $6,175.09
| Professional | | $2,326.61 | $4,421.45 | $6,175.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,458.11 / $1,458.11 / $1,741.78
| Facility | | $1,458.11 | $1,458.11 | $1,741.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.11 / $1,741.78 / $2,129.73
| Professional | | $1,458.11 | $1,741.78 | $2,129.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.16 / $106.46 / $120.28
| Professional | | $94.16 | $106.46 | $120.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,408.35 / $2,745.51 / $4,052.89
| Professional | | $2,408.35 | $2,745.51 | $4,052.89 |