- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,778.28 / $3,162.28
| Facility | | $1,071.52 | $1,778.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,023.29 / $1,288.25
| Professional | | $776.25 | $1,023.29 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $338.84 / $338.84
| Professional | | $281.84 | $338.84 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $19,498.45 / $45,708.82
| Facility | | $1,548.82 | $19,498.45 | $45,708.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $23,988.33
| Professional | | $1,445.44 | $1,819.70 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $2,089.30 / $2,089.30
| Facility | | $851.14 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Professional | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $676.08 / $1,122.02
| Professional | | $549.54 | $676.08 | $1,122.02 |