- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,098.02 / $1,098.02 / $1,098.02
| Facility | | $1,098.02 | $1,098.02 | $1,098.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.58 / $1,098.02 / $1,317.62
| Professional | | $1,056.58 | $1,098.02 | $1,317.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $4,257.83 / $12,155.63
| Facility | | $100.00 | $4,257.83 | $12,155.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.96 / $1,406.39 / $1,988.40
| Professional | | $853.96 | $1,406.39 | $1,988.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.17 / $291.17 / $299.66
| Facility | | $291.17 | $291.17 | $299.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.95 / $2,265.39 / $2,265.39
| Professional | | $1,383.95 | $2,265.39 | $2,265.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $2,550.10
| Facility | | $1,450.41 | $1,450.41 | $2,550.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.98 / $1,450.41 / $3,787.50
| Professional | | $193.98 | $1,450.41 | $3,787.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.21 / $2,049.21 / $2,049.21
| Professional | | $2,049.21 | $2,049.21 | $2,049.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.39 / $1,098.39 / $1,098.39
| Professional | | $1,098.39 | $1,098.39 | $1,098.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $12,155.63 / $12,155.63
| Facility | | $100.00 | $12,155.63 | $12,155.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.95 / $1,255.28 / $1,757.99
| Professional | | $833.95 | $1,255.28 | $1,757.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.96 / $1,310.10 / $2,511.92
| Professional | | $853.96 | $1,310.10 | $2,511.92 |