- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,599.46 / $1,599.46 / $1,599.46
| Facility | | $1,599.46 | $1,599.46 | $1,599.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,197.58 / $1,599.46 / $1,902.51
| Professional | | $1,197.58 | $1,599.46 | $1,902.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.07 / $3,513.08 / $10,029.39
| Facility | | $218.07 | $3,513.08 | $10,029.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.17 / $2,086.98 / $2,477.59
| Professional | | $1,089.17 | $2,086.98 | $2,477.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.26 / $232.66 / $299.81
| Facility | | $196.26 | $232.66 | $299.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,532.15 / $3,571.23 / $3,571.23
| Professional | | $2,532.15 | $3,571.23 | $3,571.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,717.06 / $1,717.06 / $1,717.06
| Facility | | $1,717.06 | $1,717.06 | $1,717.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.11 / $1,503.13 / $2,925.00
| Professional | | $1,452.11 | $1,503.13 | $2,925.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.66 / $1,939.66 / $1,939.66
| Professional | | $1,939.66 | $1,939.66 | $1,939.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $10,029.39 / $10,029.39
| Facility | | $100.00 | $10,029.39 | $10,029.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.99 / $1,320.43 / $2,477.59
| Professional | | $1,025.99 | $1,320.43 | $2,477.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.75 / $1,620.05 / $2,477.59
| Professional | | $1,026.75 | $1,620.05 | $2,477.59 |