- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,408.74 / $1,408.74 / $1,848.98
| Facility | | $1,408.74 | $1,408.74 | $1,848.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.74 / $1,408.74 / $1,496.79
| Professional | | $1,408.74 | $1,408.74 | $1,496.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,370.00 / $5,069.52 / $10,151.70
| Facility | | $2,370.00 | $5,069.52 | $10,151.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.73 / $657.13 / $657.13
| Professional | | $641.73 | $657.13 | $657.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.77 / $482.77 / $946.42
| Facility | | $482.77 | $482.77 | $946.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.35 / $410.35 / $1,062.52
| Professional | | $410.35 | $410.35 | $1,062.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.19 / $1,137.76 / $1,367.91
| Professional | | $778.19 | $1,137.76 | $1,367.91 |
- 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
- $1,124.05 / $1,124.05 / $1,124.05
| Professional | | $1,124.05 | $1,124.05 | $1,124.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.19 / $431.36 / $740.50
| Professional | | $329.19 | $431.36 | $740.50 |