- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,584.89 / $4,786.30
| Professional | | $933.25 | $1,584.89 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $3,467.37 / $7,244.36
| Facility | | $56.23 | $3,467.37 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,659.59 / $8,128.31
| Professional | | $1,174.90 | $1,659.59 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,467.37 / $3,801.89
| Professional | | $1,862.09 | $3,467.37 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,905.46 / $3,801.89
| Professional | | $1,023.29 | $1,905.46 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,737.80 / $8,511.38
| Facility | | $302.00 | $1,737.80 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,148.15 / $1,778.28
| Professional | | $616.60 | $1,148.15 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,311.31 / $5,888.44
| Facility | | $1,000.00 | $3,311.31 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,949.84 / $2,818.38
| Professional | | $1,096.48 | $1,949.84 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $3,467.37 / $7,244.36
| Facility | | $56.23 | $3,467.37 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,584.89 / $8,128.31
| Professional | | $1,174.90 | $1,584.89 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,754.23 / $4,677.35
| Facility | | $1,000.00 | $2,754.23 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,584.89 / $3,162.28
| Professional | | $1,148.15 | $1,584.89 | $3,162.28 |