- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.14 / $1,693.14 / $2,725.21
| Facility | | $1,044.14 | $1,693.14 | $2,725.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.14 / $1,045.15 / $1,265.50
| Professional | | $1,044.14 | $1,045.15 | $1,265.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,226.00 / $1,873.32 / $9,283.27
| Facility | | $1,226.00 | $1,873.32 | $9,283.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,045.15
| Facility | | $1,045.15 | $1,045.15 | $1,045.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,045.15
| Professional | | $1,045.15 | $1,045.15 | $1,045.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.12 / $1,358.70 / $2,116.82
| Professional | | $836.12 | $1,358.70 | $2,116.82 |
- 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
- $1,358.70 / $1,358.70 / $1,358.70
| Professional | | $1,358.70 | $1,358.70 | $1,358.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,043.55 / $1,721.86 / $1,721.86
| Facility | | $1,043.55 | $1,721.86 | $1,721.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,346.40
| Professional | | $1,045.15 | $1,045.15 | $1,346.40 |