- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $3,388.44
| Professional | | $1,659.59 | $1,659.59 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,548.13 / $5,754.40
| Professional | | $3,467.37 | $3,548.13 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $407.38 / $4,073.80
| Facility | | $269.15 | $407.38 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $478.63 / $4,786.30
| Professional | | $346.74 | $478.63 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $4,897.79
| Professional | | $3,890.45 | $3,890.45 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $1,778.28 / $6,309.57
| Professional | | $281.84 | $1,778.28 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $501.19 / $2,884.03
| Facility | | $213.80 | $501.19 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,548.82 / $3,548.13
| Professional | | $1,000.00 | $1,548.82 | $3,548.13 |