- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $6,606.93 / $10,471.29
| Facility | | $3,548.13 | $6,606.93 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,884.03 / $3,548.13
| Professional | | $2,290.87 | $2,884.03 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,677.35 / $5,623.41
| Facility | | $4,168.69 | $4,677.35 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,456.54 / $16,218.10
| Facility | | $2,290.87 | $6,456.54 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,168.69 / $4,677.35
| Professional | | $3,715.35 | $4,168.69 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $4,677.35 / $6,309.57
| Professional | | $346.74 | $4,677.35 | $6,309.57 |
- 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
- $30.20 / $30.20 / $39.81
| Professional | | $30.20 | $30.20 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $6,918.31
| Facility | | $3,467.37 | $3,467.37 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $3,467.37
| Professional | | $1,479.11 | $2,089.30 | $3,467.37 |