- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,294.26 / $2,620.87 / $4,335.77
| Facility | | $1,294.26 | $2,620.87 | $4,335.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.26 / $1,294.26 / $1,375.15
| Professional | | $1,294.26 | $1,294.26 | $1,375.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,947.48 / $7,332.42 / $27,794.14
| Facility | | $3,947.48 | $7,332.42 | $27,794.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Facility | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.40 / $1,617.32 / $2,007.37
| Professional | | $345.40 | $1,617.32 | $2,007.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.63 / $1,388.63 / $1,473.34
| Professional | | $1,388.63 | $1,388.63 | $1,473.34 |