- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,570.40 / $3,235.94
| Professional | | $1,513.56 | $2,570.40 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $5,011.87 / $9,772.37
| Facility | | $338.84 | $5,011.87 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $3,090.30 / $5,011.87
| Professional | | $446.68 | $3,090.30 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $288.40 / $380.19
| Facility | | $251.19 | $288.40 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $5,370.32
| Professional | | $1,479.11 | $1,479.11 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,715.35 / $3,715.35
| Facility | | $2,137.96 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $3,715.35 / $3,715.35
| Professional | | $218.78 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $1,288.25 / $3,162.28
| Professional | | $245.47 | $1,288.25 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $5,011.87 / $9,772.37
| Facility | | $338.84 | $5,011.87 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $3,090.30 / $5,011.87
| Professional | | $446.68 | $3,090.30 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $354.81 / $3,090.30
| Facility | | $138.04 | $354.81 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $1,288.25 / $3,090.30
| Professional | | $245.47 | $1,288.25 | $3,090.30 |