- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.20 / $1,494.20 / $1,494.20
| Facility | | $1,494.20 | $1,494.20 | $1,494.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.86 / $1,494.20 / $2,476.91
| Professional | | $1,315.86 | $1,494.20 | $2,476.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,607.71 / $6,103.61 / $25,975.45
| Facility | | $3,607.71 | $6,103.61 | $25,975.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,952.91 / $1,952.91 / $3,304.54
| Facility | | $1,952.91 | $1,952.91 | $3,304.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.62 / $1,952.91 / $3,499.88
| Professional | | $1,425.62 | $1,952.91 | $3,499.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,717.04 / $3,320.82 / $4,226.50
| Professional | | $2,717.04 | $3,320.82 | $4,226.50 |
- 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
- $3,924.61 / $3,924.61 / $3,924.61
| Professional | | $3,924.61 | $3,924.61 | $3,924.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.83 / $1,506.11 / $2,644.52
| Professional | | $1,126.83 | $1,506.11 | $2,644.52 |