- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,166.35 / $1,166.35 / $1,166.35
| Facility | | $1,166.35 | $1,166.35 | $1,166.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.36 / $1,166.35 / $1,503.08
| Professional | | $1,128.36 | $1,166.35 | $1,503.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,388.39 / $7,604.33 / $11,110.30
| Facility | | $2,388.39 | $7,604.33 | $11,110.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.98 / $1,910.59 / $2,606.90
| Professional | | $977.98 | $1,910.59 | $2,606.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,914.75 / $3,447.10 / $4,439.22
| Facility | | $2,914.75 | $3,447.10 | $4,439.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,922.79 / $1,922.79 / $2,057.94
| Professional | | $1,922.79 | $1,922.79 | $2,057.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.10 / $1,304.10 / $1,962.03
| Facility | | $1,304.10 | $1,304.10 | $1,962.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.00 / $1,304.10 / $2,545.13
| Professional | | $952.00 | $1,304.10 | $2,545.13 |
- 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
- $2,161.35 / $2,161.35 / $2,269.42
| Professional | | $2,161.35 | $2,161.35 | $2,269.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.30 / $1,564.30 / $1,564.30
| Professional | | $1,564.30 | $1,564.30 | $1,564.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,456.58 / $11,110.30 / $11,110.30
| Facility | | $4,456.58 | $11,110.30 | $11,110.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.84 / $1,331.77 / $2,606.90
| Professional | | $887.84 | $1,331.77 | $2,606.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.84 / $1,331.77 / $2,236.46
| Professional | | $887.84 | $1,331.77 | $2,236.46 |