- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,987.66 / $1,987.66 / $2,938.28
| Facility | | $1,987.66 | $1,987.66 | $2,938.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,566.58 / $2,438.32 / $2,938.28
| Professional | | $1,566.58 | $2,438.32 | $2,938.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.50 / $2,318.40 / $2,691.00
| Professional | | $1,949.50 | $2,318.40 | $2,691.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.48 / $453.97 / $3,264.58
| Facility | | $340.48 | $453.97 | $3,264.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.27 / $499.37 / $726.35
| Professional | | $431.27 | $499.37 | $726.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $4,290.42
| Facility | | $2,225.05 | $2,225.05 | $4,290.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.68 / $2,225.05 / $17,942.16
| Professional | | $343.68 | $2,225.05 | $17,942.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.61 / $1,603.03 / $3,067.47
| Professional | | $1,006.61 | $1,603.03 | $3,067.47 |