- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.72 / $3,200.26 / $4,988.88
| Facility | | $1,828.72 | $3,200.26 | $4,988.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,861.13 / $2,255.69
| Professional | | $1,828.72 | $1,861.13 | $2,255.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,361.53 / $17,799.09 / $44,527.52
| Facility | | $6,361.53 | $17,799.09 | $44,527.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $1,828.71
| Facility | | $1,828.71 | $1,828.71 | $1,828.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $1,828.71
| Professional | | $1,828.71 | $1,828.71 | $1,828.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.41 / $2,377.34 / $5,682.87
| Professional | | $1,554.41 | $2,377.34 | $5,682.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,377.34 / $2,377.34 / $2,377.34
| Professional | | $2,377.34 | $2,377.34 | $2,377.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $2,444.87
| Professional | | $1,828.72 | $1,828.72 | $2,444.87 |