- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,197.94 / $2,111.19 / $2,320.00
| Facility | | $1,197.94 | $2,111.19 | $2,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.40 / $2,111.19 / $2,320.00
| Professional | | $916.40 | $2,111.19 | $2,320.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,276.00 / $1,276.00 / $1,276.00
| Facility | | $1,276.00 | $1,276.00 | $1,276.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.00 / $1,276.00 / $1,276.00
| Professional | | $1,276.00 | $1,276.00 | $1,276.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.41 / $528.36 / $1,314.28
| Professional | | $502.41 | $528.36 | $1,314.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $25.00 / $50.00
| Professional | | $21.25 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.20 / $638.00 / $1,740.00
| Professional | | $487.20 | $638.00 | $1,740.00 |