- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.54 / $1,800.54 / $1,800.54
| Facility | | $1,800.54 | $1,800.54 | $1,800.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.58 / $1,800.54 / $3,232.08
| Professional | | $1,732.58 | $1,800.54 | $3,232.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,666.62 / $3,366.62 / $22,546.40
| Facility | | $2,666.62 | $3,366.62 | $22,546.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,562.20 / $2,799.95 / $3,206.30
| Professional | | $1,562.20 | $2,799.95 | $3,206.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.94 / $467.94 / $481.59
| Facility | | $467.94 | $467.94 | $481.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,018.29 / $3,640.83 / $3,640.83
| Professional | | $3,018.29 | $3,640.83 | $3,640.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,399.94 / $2,399.94 / $4,012.16
| Facility | | $2,399.94 | $2,399.94 | $4,012.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.90 / $2,399.94 / $5,971.88
| Professional | | $355.90 | $2,399.94 | $5,971.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,316.21 / $3,316.21 / $3,316.21
| Professional | | $3,316.21 | $3,316.21 | $3,316.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.65 / $2,666.65 / $2,666.65
| Professional | | $2,666.65 | $2,666.65 | $2,666.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $22,546.40 / $22,546.40
| Facility | | $100.00 | $22,546.40 | $22,546.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.58 / $2,042.34 / $3,467.50
| Professional | | $1,525.58 | $2,042.34 | $3,467.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.11 / $2,080.50 / $4,120.89
| Professional | | $1,527.11 | $2,080.50 | $4,120.89 |