- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,294.26 / $1,294.26 / $4,995.84
| Facility | | $1,294.26 | $1,294.26 | $4,995.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.26 / $1,294.26 / $1,294.26
| Professional | | $1,294.26 | $1,294.26 | $1,294.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.05
| Facility | | $0.02 | $0.02 | $0.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,887.45 / $1,887.45 / $2,022.27
| Facility | | $1,887.45 | $1,887.45 | $2,022.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $609.63 / $1,294.26 / $1,920.19
| Facility | | $609.63 | $1,294.26 | $1,920.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Professional | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,675.86 / $1,675.86 / $1,675.86
| Facility | | $1,675.86 | $1,675.86 | $1,675.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.63 / $1,388.63 / $1,388.63
| Professional | | $1,388.63 | $1,388.63 | $1,388.63 |