- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,819.70 / $2,290.87
| Facility | | $851.14 | $1,819.70 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $933.25 / $2,290.87
| Professional | | $831.76 | $933.25 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $12,882.50
| Facility | | $12,882.50 | $12,882.50 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,380.38 / $2,137.96
| Professional | | $851.14 | $1,380.38 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,071.52 / $10,471.29
| Facility | | $489.78 | $1,071.52 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,995.26
| Professional | | $812.83 | $1,000.00 | $1,995.26 |