- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.41 / $617.41 / $617.41
| Facility | | $617.41 | $617.41 | $617.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.41 / $617.41 / $817.27
| Professional | | $617.41 | $617.41 | $817.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,923.92 / $2,212.09
| Facility | | $100.00 | $1,923.92 | $2,212.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.02 / $1,031.02 / $1,031.02
| Professional | | $1,031.02 | $1,031.02 | $1,031.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $925.16 / $1,276.72 / $2,312.90
| Facility | | $925.16 | $1,276.72 | $2,312.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $3,504.00 / $9,239.00
| Facility | | $83.43 | $3,504.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.98 / $844.83 / $844.83
| Professional | | $704.98 | $844.83 | $844.83 |
- 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
- $1,031.02 / $1,031.02 / $1,031.02
| Professional | | $1,031.02 | $1,031.02 | $1,031.02 |