- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.00 / $1,705.42 / $6,449.37
| Facility | | $1,201.00 | $1,705.42 | $6,449.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.00 / $1,201.00 / $1,201.00
| Professional | | $1,201.00 | $1,201.00 | $1,201.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $487.20 / $1,916.52 / $3,187.51
| Facility | | $487.20 | $1,916.52 | $3,187.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.90 / $101.60 / $127.00
| Professional | | $88.90 | $101.60 | $127.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,432.85 / $2,432.85 / $2,471.48
| Facility | | $2,432.85 | $2,432.85 | $2,471.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.00 / $1,321.10 / $2,215.23
| Facility | | $1,201.00 | $1,321.10 | $2,215.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.50 / $950.50 / $2,138.63
| Facility | | $950.50 | $950.50 | $2,138.63 |