- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.72 / $1,530.86 / $9,206.45
| Facility | | $1,275.72 | $1,530.86 | $9,206.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.72 / $1,445.82 / $1,913.58
| Professional | | $1,275.72 | $1,445.82 | $1,913.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,049.48 / $1,469.28 / $7,994.08
| Facility | | $1,049.48 | $1,469.28 | $7,994.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.91 / $2,589.91 / $3,103.00
| Professional | | $2,589.91 | $2,589.91 | $3,103.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.72 / $1,275.72 / $1,807.27
| Professional | | $1,275.72 | $1,275.72 | $1,807.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $70.00
| Professional | | $40.00 | $40.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.43 / $1,275.72 / $1,913.58
| Facility | | $765.43 | $1,275.72 | $1,913.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.17 / $893.00 / $3,331.46
| Professional | | $744.17 | $893.00 | $3,331.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.72 / $1,275.72 / $1,275.72
| Professional | | $1,275.72 | $1,275.72 | $1,275.72 |