- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,648.16 / $3,031.45 / $3,484.42
| Facility | | $2,648.16 | $3,031.45 | $3,484.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,648.16 / $3,031.45 / $3,484.42
| Professional | | $2,648.16 | $3,031.45 | $3,484.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.81 / $3,843.85 / $16,898.30
| Facility | | $3,660.81 | $3,843.85 | $16,898.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,829.31 / $1,868.90 / $3,011.14
| Professional | | $1,829.31 | $1,868.90 | $3,011.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $4,286.31
| Professional | | $1,275.00 | $1,275.00 | $4,286.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $5,804.84 / $17,132.59
| Facility | | $100.00 | $5,804.84 | $17,132.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.05 / $2,311.51 / $4,264.22
| Professional | | $1,810.05 | $2,311.51 | $4,264.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.05 / $2,392.17 / $6,009.93
| Professional | | $1,810.05 | $2,392.17 | $6,009.93 |