- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,757.14 / $1,757.14 / $1,757.14
| Facility | | $1,757.14 | $1,757.14 | $1,757.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,731.40 / $1,757.14 / $2,108.57
| Professional | | $1,731.40 | $1,757.14 | $2,108.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $3,147.60 / $3,304.98
| Facility | | $80.00 | $3,147.60 | $3,304.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $392.73 / $3,246.29
| Professional | | $136.66 | $392.73 | $3,246.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,479.70 / $3,625.31 / $3,625.31
| Professional | | $3,479.70 | $3,625.31 | $3,625.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $4,080.53
| Facility | | $2,569.13 | $2,569.13 | $4,080.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.38 / $2,569.13 / $6,060.94
| Professional | | $310.38 | $2,569.13 | $6,060.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $80.00 / $100.00
| Facility | | $80.00 | $80.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $200.63 / $2,069.19
| Professional | | $136.66 | $200.63 | $2,069.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $200.96 / $463.76
| Professional | | $136.66 | $200.96 | $463.76 |