- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,082.88 / $1,082.88 / $1,560.00
| Facility | | $1,082.88 | $1,082.88 | $1,560.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.00 / $1,170.00 / $1,170.00
| Professional | | $420.00 | $1,170.00 | $1,170.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $468.00 / $1,248.00 / $2,340.00
| Facility | | $468.00 | $1,248.00 | $2,340.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $721.92 / $1,170.00 / $1,287.00
| Facility | | $721.92 | $1,170.00 | $1,287.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $600.00 / $720.00
| Professional | | $600.00 | $600.00 | $720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $1,170.00
| Professional | | $30.00 | $30.00 | $1,170.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.00 / $1,200.00 / $2,160.00
| Facility | | $900.00 | $1,200.00 | $2,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.50 / $896.50 / $926.94
| Professional | | $896.50 | $896.50 | $926.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.00 / $252.00 / $960.00
| Professional | | $252.00 | $252.00 | $960.00 |