- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,209.78 / $1,209.78 / $1,209.78
| Facility | | $1,209.78 | $1,209.78 | $1,209.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.29 / $1,003.86 / $1,209.78
| Professional | | $862.29 | $1,003.86 | $1,209.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,565.50 / $2,565.50 / $2,565.50
| Facility | | $2,565.50 | $2,565.50 | $2,565.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.95 / $2,337.67 / $2,922.10
| Professional | | $1,478.95 | $2,337.67 | $2,922.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $1,214.67 / $6,113.25
| Facility | | $0.02 | $1,214.67 | $6,113.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.37 / $1,158.30 / $2,359.84
| Professional | | $656.37 | $1,158.30 | $2,359.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,660.79 / $2,359.84 / $2,860.06
| Facility | | $1,660.79 | $2,359.84 | $2,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.40 / $2,359.84 / $3,359.07
| Professional | | $1,544.40 | $2,359.84 | $3,359.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.41 / $3,100.77 / $3,535.65
| Professional | | $1,840.41 | $3,100.77 | $3,535.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.54 / $1,158.30 / $1,698.84
| Professional | | $540.54 | $1,158.30 | $1,698.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.00 / $1,287.00 / $1,287.00
| Professional | | $1,287.00 | $1,287.00 | $1,287.00 |