- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,388.44 / $5,754.40
| Facility | | $1,995.26 | $3,388.44 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $2,137.96
| Professional | | $1,288.25 | $1,584.89 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,630.27 / $3,162.28
| Facility | | $2,344.23 | $2,630.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,073.80 / $8,912.51
| Facility | | $1,258.93 | $4,073.80 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,344.23 / $2,818.38
| Professional | | $2,238.72 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $2,630.27 / $3,548.13
| Professional | | $346.74 | $2,630.27 | $3,548.13 |
- 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
- $1,949.84 / $1,949.84 / $3,890.45
| Facility | | $1,949.84 | $1,949.84 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $1,949.84
| Professional | | $812.83 | $1,174.90 | $1,949.84 |