- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,760.83 / $10,471.29
| Facility | | $3,715.35 | $6,760.83 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,951.21 / $3,890.45
| Professional | | $2,454.71 | $2,951.21 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,786.30 / $5,754.40
| Facility | | $4,265.80 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $7,413.10 / $16,218.10
| Facility | | $2,290.87 | $7,413.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,073.80 / $5,370.32
| Professional | | $1,737.80 | $4,073.80 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $4,570.88 / $6,309.57
| Professional | | $346.74 | $4,570.88 | $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
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,548.13 / $7,079.46
| Facility | | $2,630.27 | $3,548.13 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $3,548.13
| Professional | | $1,479.11 | $2,089.30 | $3,548.13 |