- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,241.06 / $1,241.06 / $1,241.06
| Facility | | $1,241.06 | $1,241.06 | $1,241.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.18 / $1,241.06 / $1,988.58
| Professional | | $1,194.18 | $1,241.06 | $1,988.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,036.55 / $2,476.59 / $11,540.27
| Facility | | $2,036.55 | $2,476.59 | $11,540.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.35 / $2,358.66 / $2,460.51
| Professional | | $1,179.35 | $2,358.66 | $2,460.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,846.52 / $2,846.52 / $2,929.52
| Facility | | $2,846.52 | $2,846.52 | $2,929.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $2,111.63
| Facility | | $1,772.06 | $1,772.06 | $2,111.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.25 / $1,772.06 / $3,539.06
| Professional | | $1,506.25 | $1,772.06 | $3,539.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.28 / $2,017.28 / $2,017.28
| Professional | | $2,017.28 | $2,017.28 | $2,017.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,886.93 / $1,886.93 / $2,246.44
| Professional | | $1,886.93 | $1,886.93 | $2,246.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $11,540.27 / $11,540.27
| Facility | | $100.00 | $11,540.27 | $11,540.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.05 / $1,364.31 / $2,190.53
| Professional | | $928.05 | $1,364.31 | $2,190.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.53 / $1,095.27 / $1,516.82
| Facility | | $109.53 | $1,095.27 | $1,516.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.20 / $1,364.31 / $2,450.89
| Professional | | $907.20 | $1,364.31 | $2,450.89 |