- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,352.62 / $1,352.62 / $1,352.62
| Facility | | $1,352.62 | $1,352.62 | $1,352.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.55 / $1,352.62 / $1,623.14
| Professional | | $1,301.55 | $1,352.62 | $1,623.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,215.73 / $2,571.98 / $14,397.39
| Facility | | $2,215.73 | $2,571.98 | $14,397.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.49 / $1,994.16 / $2,419.58
| Professional | | $1,011.49 | $1,994.16 | $2,419.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.68 / $358.68 / $369.14
| Facility | | $358.68 | $358.68 | $369.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.28 / $2,790.80 / $2,790.80
| Professional | | $1,954.28 | $2,790.80 | $2,790.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $3,020.16
| Facility | | $1,406.76 | $1,406.76 | $3,020.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.74 / $1,406.76 / $4,485.93
| Professional | | $229.74 | $1,406.76 | $4,485.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,524.46 / $2,524.46 / $2,524.46
| Professional | | $2,524.46 | $2,524.46 | $2,524.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.58 / $1,772.58 / $2,422.44
| Professional | | $1,772.58 | $1,772.58 | $2,422.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $14,397.39 / $14,397.39
| Facility | | $100.00 | $14,397.39 | $14,397.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.78 / $1,551.76 / $2,082.02
| Professional | | $987.78 | $1,551.76 | $2,082.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.49 / $1,561.52 / $2,975.18
| Professional | | $1,011.49 | $1,561.52 | $2,975.18 |