- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.25 / $1,165.25 / $1,165.25
| Facility | | $1,165.25 | $1,165.25 | $1,165.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.94 / $1,165.25 / $1,294.72
| Professional | | $890.94 | $1,165.25 | $1,294.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.87 / $2,040.40 / $2,448.48
| Facility | | $1,747.87 | $2,040.40 | $2,448.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.32 / $1,938.38 / $2,040.40
| Professional | | $1,632.32 | $1,938.38 | $2,040.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.87 / $6,000.39 / $16,665.58
| Facility | | $109.87 | $6,000.39 | $16,665.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,253.75 / $2,388.98 / $2,862.26
| Professional | | $2,253.75 | $2,388.98 | $2,862.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,562.36 / $5,757.08 / $13,122.50
| Facility | | $3,562.36 | $5,757.08 | $13,122.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,253.75 / $2,253.75 / $2,320.00
| Professional | | $2,253.75 | $2,253.75 | $2,320.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.96 / $194.32 / $1,165.25
| Facility | | $174.96 | $194.32 | $1,165.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.94 / $92.02 / $784.20
| Professional | | $54.94 | $92.02 | $784.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.94 / $92.02 / $353.65
| Professional | | $54.94 | $92.02 | $353.65 |