- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,246.63 / $1,246.63 / $1,246.63
| Facility | | $1,246.63 | $1,246.63 | $1,246.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.40 / $1,246.63 / $2,117.16
| Professional | | $933.40 | $1,246.63 | $2,117.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.36 / $2,248.46 / $15,122.05
| Facility | | $1,895.36 | $2,248.46 | $15,122.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.26 / $1,990.13 / $2,163.09
| Professional | | $1,057.26 | $1,990.13 | $2,163.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.66 / $300.66 / $309.43
| Facility | | $300.66 | $300.66 | $309.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.64 / $2,339.25 / $2,339.25
| Professional | | $2,089.64 | $2,339.25 | $2,339.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $2,628.00
| Facility | | $1,350.00 | $1,350.00 | $2,628.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.50 / $1,350.00 / $3,862.50
| Professional | | $1,147.50 | $1,350.00 | $3,862.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,130.81 / $2,130.81 / $2,130.81
| Professional | | $2,130.81 | $2,130.81 | $2,130.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.36 / $1,895.36 / $2,457.88
| Professional | | $1,895.36 | $1,895.36 | $2,457.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $15,122.05 / $15,122.05
| Facility | | $100.00 | $15,122.05 | $15,122.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.56 / $1,374.43 / $2,322.30
| Professional | | $1,025.56 | $1,374.43 | $2,322.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.20 / $1,857.84 / $2,588.80
| Professional | | $1,056.20 | $1,857.84 | $2,588.80 |