- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,444.41 / $1,444.41 / $1,444.41
| Facility | | $1,444.41 | $1,444.41 | $1,444.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.18 / $1,444.41 / $2,442.90
| Professional | | $932.18 | $1,444.41 | $2,442.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,366.09 / $2,746.49 / $15,373.38
| Facility | | $2,366.09 | $2,746.49 | $15,373.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.13 / $2,129.48 / $2,583.77
| Professional | | $1,080.13 | $2,129.48 | $2,583.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $383.02 / $383.02 / $394.19
| Facility | | $383.02 | $383.02 | $394.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,086.89 / $2,980.10 / $2,980.10
| Professional | | $2,086.89 | $2,980.10 | $2,980.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $3,225.16
| Facility | | $1,440.00 | $1,440.00 | $3,225.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.00 / $1,440.00 / $4,790.63
| Professional | | $1,224.00 | $1,440.00 | $4,790.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.70 / $2,695.70 / $2,695.70
| Professional | | $2,695.70 | $2,695.70 | $2,695.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,892.88 / $1,892.88 / $2,587.84
| Professional | | $1,892.88 | $1,892.88 | $2,587.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $15,373.38 / $15,373.38
| Facility | | $100.00 | $15,373.38 | $15,373.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.81 / $1,656.98 / $2,223.44
| Professional | | $1,054.81 | $1,656.98 | $2,223.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.81 / $1,656.98 / $3,176.87
| Professional | | $1,054.81 | $1,656.98 | $3,176.87 |