- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,775.14 / $2,775.14 / $2,775.14
| Facility | | $2,775.14 | $2,775.14 | $2,775.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.30 / $2,775.14 / $3,330.17
| Professional | | $2,670.30 | $2,775.14 | $3,330.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,559.40 / $3,516.30 / $4,264.28
| Facility | | $2,559.40 | $3,516.30 | $4,264.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.32 / $2,687.37 / $3,341.42
| Professional | | $1,361.32 | $2,687.37 | $3,341.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,101.40 / $3,142.31 / $3,142.31
| Professional | | $3,101.40 | $3,142.31 | $3,142.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.45 / $2,671.66 / $5,643.75
| Professional | | $318.45 | $2,671.66 | $5,643.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,862.23 / $2,862.23 / $2,862.23
| Professional | | $2,862.23 | $2,862.23 | $2,862.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $4,264.28 / $4,264.28
| Facility | | $100.00 | $4,264.28 | $4,264.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.04 / $1,724.55 / $2,766.93
| Professional | | $1,351.04 | $1,724.55 | $2,766.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.50 / $1,798.50 / $3,434.80
| Professional | | $1,352.50 | $1,798.50 | $3,434.80 |