- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,183.88 / $1,183.88 / $1,183.88
| Facility | | $1,183.88 | $1,183.88 | $1,183.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.09 / $1,183.88 / $1,420.66
| Professional | | $1,139.09 | $1,183.88 | $1,420.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,036.14 / $4,590.05 / $13,104.06
| Facility | | $2,036.14 | $4,590.05 | $13,104.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.80 / $1,978.54 / $2,225.86
| Professional | | $1,147.80 | $1,978.54 | $2,225.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $313.93 / $313.93 / $323.08
| Facility | | $313.93 | $313.93 | $323.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.36 / $2,442.50 / $2,442.50
| Professional | | $1,710.36 | $2,442.50 | $2,442.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $2,748.85
| Facility | | $213.28 | $1,414.26 | $2,748.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.10 / $1,414.26 / $3,266.25
| Professional | | $209.10 | $1,414.26 | $3,266.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.46 / $2,209.46 / $2,209.46
| Professional | | $2,209.46 | $2,209.46 | $2,209.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.37 / $1,613.37 / $1,613.37
| Professional | | $1,613.37 | $1,613.37 | $1,613.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $13,104.06 / $13,104.06
| Facility | | $100.00 | $13,104.06 | $13,104.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.15 / $1,393.98 / $2,416.80
| Professional | | $1,093.15 | $1,393.98 | $2,416.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.15 / $1,812.60 / $2,646.00
| Professional | | $1,093.15 | $1,812.60 | $2,646.00 |