- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,590.54
| Facility | | $1,590.54 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,638.26
| Professional | | $1,590.54 | $1,590.54 | $1,638.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $3,825.00
| Facility | | $1.00 | $1.00 | $3,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.29 / $1,571.13 / $1,653.82
| Professional | | $138.29 | $1,571.13 | $1,653.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.80 / $5,216.72 / $7,332.55
| Facility | | $2,838.80 | $5,216.72 | $7,332.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,909.85 / $2,198.53 / $2,401.48
| Professional | | $1,909.85 | $2,198.53 | $2,401.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,521.25 / $4,780.79 / $6,607.69
| Facility | | $2,521.25 | $4,780.79 | $6,607.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,890.94 / $1,890.94 / $2,017.00
| Professional | | $1,890.94 | $1,890.94 | $2,017.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,653.82 / $1,653.82 / $3,644.72
| Facility | | $1,653.82 | $1,653.82 | $3,644.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.82 / $1,653.82 / $3,793.70
| Professional | | $1,653.82 | $1,653.82 | $3,793.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $2,883.33
| Professional | | $1,590.54 | $1,590.54 | $2,883.33 |