- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,372.96 / $1,372.96 / $1,372.96
| Facility | | $1,372.96 | $1,372.96 | $1,372.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.61 / $1,372.96 / $1,665.83
| Professional | | $645.61 | $1,372.96 | $1,665.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,230.40 / $2,633.16 / $2,747.64
| Facility | | $2,230.40 | $2,633.16 | $2,747.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.80 / $2,233.50 / $2,404.19
| Professional | | $1,786.80 | $2,233.50 | $2,404.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $5,752.66
| Facility | | $173.31 | $1,082.51 | $5,752.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,655.00 / $2,681.55 / $3,371.85
| Professional | | $2,655.00 | $2,681.55 | $3,371.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,069.31 / $4,069.31 / $4,529.66
| Facility | | $4,069.31 | $4,069.31 | $4,529.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,655.00 / $2,655.00 / $2,655.00
| Professional | | $2,655.00 | $2,655.00 | $2,655.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.97 / $626.80 / $10,273.09
| Facility | | $228.97 | $626.80 | $10,273.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.40 / $1,077.96 / $2,289.69
| Professional | | $642.40 | $1,077.96 | $2,289.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.40 / $1,077.96 / $2,093.69
| Professional | | $642.40 | $1,077.96 | $2,093.69 |