- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.58 / $1,375.58 / $2,033.47
| Facility | | $1,375.58 | $1,375.58 | $2,033.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.58 / $1,901.50 / $2,033.47
| Professional | | $1,375.58 | $1,901.50 | $2,033.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.67 / $2,208.32 / $2,315.98
| Professional | | $1,828.67 | $2,208.32 | $2,315.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.66 / $477.94 / $3,703.73
| Facility | | $310.66 | $477.94 | $3,703.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.60 / $525.73 / $5,000.03
| Professional | | $336.60 | $525.73 | $5,000.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.09 / $1,850.09 / $3,497.79
| Facility | | $1,850.09 | $1,850.09 | $3,497.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,344.05 / $1,572.58 / $14,627.50
| Professional | | $1,344.05 | $1,572.58 | $14,627.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $2,249.67
| Professional | | $100.00 | $100.00 | $2,249.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.76 / $1,960.22 / $2,907.65
| Professional | | $1,036.76 | $1,960.22 | $2,907.65 |