- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,722.92 / $4,061.18 / $11,189.90
| Facility | | $1,722.92 | $4,061.18 | $11,189.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.06 / $1,367.40 / $1,845.99
| Professional | | $1,242.06 | $1,367.40 | $1,845.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $80.00 / $80.00
| Facility | | $80.00 | $80.00 | $80.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,481.35 / $5,348.71 / $10,153.70
| Facility | | $1,481.35 | $5,348.71 | $10,153.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,775.96 / $2,775.96 / $3,325.92
| Professional | | $2,775.96 | $2,775.96 | $3,325.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,646.40 / $10,825.25 / $10,825.25
| Facility | | $3,646.40 | $10,825.25 | $10,825.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,349.42 / $11,349.42 / $17,092.50
| Professional | | $11,349.42 | $11,349.42 | $17,092.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,367.40 / $2,279.00 / $3,335.55
| Facility | | $1,367.40 | $2,279.00 | $3,335.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,279.00 / $2,279.00 / $2,848.75
| Professional | | $2,279.00 | $2,279.00 | $2,848.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.10 / $2,848.75 / $5,127.75
| Professional | | $2,051.10 | $2,848.75 | $5,127.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.12 / $2,346.46 / $8,208.41
| Facility | | $1,526.12 | $2,346.46 | $8,208.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,153.78 / $2,848.75 / $3,988.25
| Professional | | $2,153.78 | $2,848.75 | $3,988.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.18 / $957.18 / $1,367.40
| Professional | | $957.18 | $957.18 | $1,367.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.00 / $800.00 / $2,279.00
| Professional | | $800.00 | $800.00 | $2,279.00 |