- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.58 / $1,800.58 / $2,661.72
| Facility | | $1,800.58 | $1,800.58 | $2,661.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.58 / $2,489.01 / $2,661.72
| Professional | | $1,800.58 | $2,489.01 | $2,661.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.46 / $2,892.80 / $3,033.82
| Professional | | $2,395.46 | $2,892.80 | $3,033.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.07 / $659.34 / $6,799.44
| Facility | | $309.07 | $659.34 | $6,799.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.09 / $679.95 / $7,029.77
| Professional | | $412.09 | $679.95 | $7,029.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,399.94 / $2,399.94 / $4,581.95
| Facility | | $2,399.94 | $2,399.94 | $4,581.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,760.62 / $2,399.94 / $3,406.69
| Professional | | $1,760.62 | $2,399.94 | $3,406.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $2,944.78
| Professional | | $100.00 | $100.00 | $2,944.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.08 / $2,153.76 / $2,908.78
| Professional | | $1,357.08 | $2,153.76 | $2,908.78 |