- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,050.72 / $1,050.72 / $1,050.72
| Facility | | $1,050.72 | $1,050.72 | $1,050.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.84 / $1,050.72 / $1,050.72
| Professional | | $89.84 | $1,050.72 | $1,050.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.45 / $1,528.56 / $1,647.63
| Facility | | $165.45 | $1,528.56 | $1,647.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.10 / $1,565.25 / $1,647.63
| Professional | | $1,318.10 | $1,565.25 | $1,647.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.00 / $5,083.78 / $14,119.76
| Facility | | $120.00 | $5,083.78 | $14,119.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.25 / $2,024.87 / $2,426.02
| Professional | | $1,910.25 | $2,024.87 | $2,426.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,018.18 / $4,877.64 / $11,117.93
| Facility | | $3,018.18 | $4,877.64 | $11,117.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.25 / $1,910.25 / $1,965.60
| Professional | | $1,910.25 | $1,910.25 | $1,965.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.31 / $1,647.63 / $7,674.31
| Facility | | $1,078.31 | $1,647.63 | $7,674.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.08 / $77.18 / $287.94
| Professional | | $46.08 | $77.18 | $287.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.08 / $77.30 / $296.64
| Professional | | $46.08 | $77.30 | $296.64 |