- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,125.11 / $1,125.11 / $1,125.11
| Facility | | $1,125.11 | $1,125.11 | $1,125.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.11 / $1,125.11 / $1,449.94
| Professional | | $1,125.11 | $1,125.11 | $1,449.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,387.50 / $4,596.79 / $10,300.32
| Facility | | $1,387.50 | $4,596.79 | $10,300.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.40 / $1,548.53 / $2,514.73
| Professional | | $943.40 | $1,548.53 | $2,514.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,733.17 / $3,325.22 / $4,282.26
| Facility | | $2,733.17 | $3,325.22 | $4,282.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,686.18 / $1,985.17 / $1,985.17
| Professional | | $1,686.18 | $1,985.17 | $1,985.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,206.80 / $1,489.46 / $1,805.27
| Facility | | $1,206.80 | $1,489.46 | $1,805.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.96 / $1,206.80 / $2,985.38
| Professional | | $880.96 | $1,206.80 | $2,985.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,084.92 / $2,084.92 / $2,189.17
| Professional | | $2,084.92 | $2,084.92 | $2,189.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.34 / $1,229.34 / $1,229.34
| Professional | | $1,229.34 | $1,229.34 | $1,229.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,227.41 / $10,300.32 / $10,300.32
| Facility | | $5,227.41 | $10,300.32 | $10,300.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.45 / $1,284.68 / $2,514.73
| Professional | | $856.45 | $1,284.68 | $2,514.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.45 / $1,284.68 / $2,349.67
| Professional | | $856.45 | $1,284.68 | $2,349.67 |