- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,234.77 / $1,645.41 / $2,159.60
| Facility | | $1,234.77 | $1,645.41 | $2,159.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.41 / $1,645.41 / $1,748.25
| Professional | | $1,645.41 | $1,645.41 | $1,748.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,291.76 / $2,933.67 / $21,537.26
| Facility | | $1,291.76 | $2,933.67 | $21,537.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.76 / $2,056.76 / $2,056.76
| Professional | | $2,056.76 | $2,056.76 | $2,056.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Facility | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Professional | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.40 / $2,167.46 / $2,616.12
| Professional | | $345.40 | $2,167.46 | $2,616.12 |
- 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
- $30.00 / $30.00 / $2,500.00
| Professional | | $30.00 | $30.00 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.97 / $1,713.97 / $1,936.79
| Professional | | $1,713.97 | $1,713.97 | $1,936.79 |