- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.67 / $1,366.67 / $1,366.67
| Facility | | $1,366.67 | $1,366.67 | $1,366.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.55 / $1,366.67 / $2,265.50
| Professional | | $1,203.55 | $1,366.67 | $2,265.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,299.25 / $5,581.75 / $23,758.59
| Facility | | $3,299.25 | $5,581.75 | $23,758.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.57 / $2,098.57 / $2,611.67
| Professional | | $2,098.57 | $2,098.57 | $2,611.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.24 / $1,786.24 / $3,022.51
| Facility | | $1,786.24 | $1,786.24 | $3,022.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.96 / $1,786.24 / $3,201.00
| Professional | | $1,303.96 | $1,786.24 | $3,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,485.14 / $3,228.75 / $3,941.37
| Professional | | $2,485.14 | $3,228.75 | $3,941.37 |
- 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
- $3,589.65 / $3,589.65 / $3,589.65
| Professional | | $3,589.65 | $3,589.65 | $3,589.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.29 / $1,377.57 / $2,418.82
| Professional | | $1,051.29 | $1,377.57 | $2,418.82 |