- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,056.00 / $7,342.65 / $15,442.32
| Facility | | $2,056.00 | $7,342.65 | $15,442.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,793.30 / $3,793.30 / $4,020.80
| Professional | | $3,793.30 | $3,793.30 | $4,020.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,338.52 / $3,196.56 / $7,384.48
| Facility | | $2,338.52 | $3,196.56 | $7,384.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.87 / $655.87 / $655.87
| Professional | | $655.87 | $655.87 | $655.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.27 / $236.27 / $236.27
| Professional | | $236.27 | $236.27 | $236.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,056.00 / $6,722.10 / $15,442.32
| Facility | | $2,056.00 | $6,722.10 | $15,442.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.72 / $1,196.72 / $1,388.19
| Professional | | $1,196.72 | $1,196.72 | $1,388.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $75.00
| Professional | | $30.00 | $30.00 | $75.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.00 / $1,438.00 / $1,844.00
| Facility | | $300.00 | $1,438.00 | $1,844.00 |