- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,296.46 / $2,296.46 / $3,394.76
| Facility | | $2,296.46 | $2,296.46 | $3,394.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,296.46 / $3,174.48 / $3,394.76
| Professional | | $2,296.46 | $3,174.48 | $3,394.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,073.91 / $3,712.10 / $3,893.06
| Professional | | $3,073.91 | $3,712.10 | $3,893.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.62 / $765.86 / $7,152.08
| Facility | | $396.62 | $765.86 | $7,152.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.39 / $765.86 / $8,656.58
| Professional | | $502.39 | $765.86 | $8,656.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $5,838.74
| Facility | | $3,248.38 | $3,248.38 | $5,838.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.13 / $3,248.38 / $24,417.11
| Professional | | $415.13 | $3,248.38 | $24,417.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $3,755.76
| Professional | | $100.00 | $100.00 | $3,755.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.84 / $2,763.76 / $3,732.61
| Professional | | $1,730.84 | $2,763.76 | $3,732.61 |