- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,124.94 / $2,124.94 / $2,124.94
| Facility | | $2,124.94 | $2,124.94 | $2,124.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.52 / $2,124.94 / $3,262.35
| Professional | | $1,652.52 | $2,124.94 | $3,262.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,129.34 / $8,677.94 / $36,940.37
| Facility | | $5,129.34 | $8,677.94 | $36,940.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.61 / $2,717.61 / $4,597.87
| Facility | | $2,717.61 | $2,717.61 | $4,597.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $2,717.61 / $4,977.38
| Professional | | $1,983.86 | $2,717.61 | $4,977.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,469.32 / $4,293.29 / $5,374.76
| Professional | | $3,469.32 | $4,293.29 | $5,374.76 |
- 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
- $5,581.28 / $5,581.28 / $5,581.28
| Professional | | $5,581.28 | $5,581.28 | $5,581.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,423.68 / $3,462.41 / $3,635.53
| Professional | | $2,423.68 | $3,462.41 | $3,635.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.57 / $2,141.88 / $3,585.85
| Professional | | $1,634.57 | $2,141.88 | $3,585.85 |