- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.40 / $1,000.40 / $1,000.40
| Facility | | $1,000.40 | $1,000.40 | $1,000.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.61 / $1,000.40 / $1,200.48
| Professional | | $645.61 | $1,000.40 | $1,200.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,310.98 / $1,902.18 / $10,647.60
| Facility | | $1,310.98 | $1,902.18 | $10,647.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.09 / $1,392.92 / $1,789.50
| Professional | | $748.09 | $1,392.92 | $1,789.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.27 / $265.27 / $273.02
| Facility | | $265.27 | $265.27 | $273.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.36 / $2,064.00 / $2,064.00
| Professional | | $1,445.36 | $2,064.00 | $2,064.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $2,233.78
| Facility | | $173.31 | $1,082.51 | $2,233.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.91 / $1,082.51 / $2,655.00
| Professional | | $169.91 | $1,082.51 | $2,655.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.10 / $1,867.10 / $1,867.10
| Professional | | $1,867.10 | $1,867.10 | $1,867.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.98 / $1,310.98 / $1,799.85
| Professional | | $1,310.98 | $1,310.98 | $1,799.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $10,647.60 / $10,647.60
| Facility | | $100.00 | $10,647.60 | $10,647.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.56 / $1,147.64 / $1,539.94
| Professional | | $730.56 | $1,147.64 | $1,539.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.09 / $1,156.31 / $2,312.61
| Professional | | $748.09 | $1,156.31 | $2,312.61 |