- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.63 / $1,233.63 / $1,823.62
| Facility | | $1,233.63 | $1,233.63 | $1,823.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.63 / $1,674.60 / $1,823.62
| Professional | | $1,233.63 | $1,674.60 | $1,823.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.70 / $1,977.93 / $2,074.35
| Professional | | $1,411.70 | $1,977.93 | $2,074.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.58 / $408.54 / $4,085.38
| Facility | | $233.58 | $408.54 | $4,085.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.75 / $450.80 / $4,663.01
| Professional | | $281.75 | $450.80 | $4,663.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $2,663.06
| Facility | | $213.28 | $1,414.26 | $2,663.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $2,823.39
| Professional | | $213.28 | $1,414.26 | $2,823.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $2,023.10
| Professional | | $100.00 | $100.00 | $2,023.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.12 / $1,543.26 / $2,186.29
| Professional | | $937.12 | $1,543.26 | $2,186.29 |