- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,007.82 / $3,915.25 / $6,390.74
| Facility | | $2,007.82 | $3,915.25 | $6,390.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.39 / $2,007.82 / $3,112.12
| Professional | | $1,885.39 | $2,007.82 | $3,112.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,232.09 / $10,105.69 / $35,690.43
| Facility | | $3,232.09 | $10,105.69 | $35,690.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.50 / $1,689.51 / $1,885.39
| Professional | | $3.50 | $1,689.51 | $1,885.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,106.72 / $5,984.41 / $11,272.27
| Facility | | $3,106.72 | $5,984.41 | $11,272.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.84 / $2,841.91 / $4,133.17
| Professional | | $1,137.84 | $2,841.91 | $4,133.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,497.53 / $3,917.70 / $5,687.79
| Professional | | $2,497.53 | $3,917.70 | $5,687.79 |
- 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
- $3,183.13 / $3,183.13 / $3,183.13
| Professional | | $3,183.13 | $3,183.13 | $3,183.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,330.04 / $3,330.04 / $3,672.84
| Professional | | $3,330.04 | $3,330.04 | $3,672.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,469.14 / $2,448.56
| Professional | | $1,028.40 | $1,469.14 | $2,448.56 |