- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $758.58 / $1,047.13
| Professional | | $549.54 | $758.58 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $2,398.83
| Facility | | $1,000.00 | $1,202.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,023.29
| Professional | | $912.01 | $912.01 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $758.58 / $758.58
| Facility | | $537.03 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $1,000.00
| Professional | | $549.54 | $549.54 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $660.69 / $891.25
| Professional | | $602.56 | $660.69 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,071.52 / $1,862.09
| Facility | | $512.86 | $1,071.52 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $602.56 / $954.99
| Facility | | $407.38 | $602.56 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $602.56 / $912.01
| Professional | | $467.74 | $602.56 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $10,964.78
| Professional | | $7,079.46 | $7,079.46 | $10,964.78 |