- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,192.90 / $1,192.90 / $1,192.90
| Facility | | $1,192.90 | $1,192.90 | $1,192.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.90 / $1,192.90 / $1,582.85
| Professional | | $1,192.90 | $1,192.90 | $1,582.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,398.38 / $4,632.83 / $14,901.61
| Facility | | $1,398.38 | $4,632.83 | $14,901.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.48 / $1,861.69 / $2,666.21
| Professional | | $1,066.48 | $1,861.69 | $2,666.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,897.82 / $3,525.53 / $4,540.22
| Facility | | $2,897.82 | $3,525.53 | $4,540.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,966.55 / $2,104.76 / $2,104.76
| Professional | | $1,966.55 | $2,104.76 | $2,104.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,549.06 / $1,579.21 / $1,914.03
| Facility | | $1,549.06 | $1,579.21 | $1,914.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.81 / $1,549.06 / $3,056.63
| Professional | | $1,130.81 | $1,549.06 | $3,056.63 |
- 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
- $2,210.52 / $2,210.52 / $2,321.05
| Professional | | $2,210.52 | $2,210.52 | $2,321.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.76 / $1,808.76 / $1,808.76
| Professional | | $1,808.76 | $1,808.76 | $1,808.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,352.48 / $14,901.61 / $14,901.61
| Facility | | $5,352.48 | $14,901.61 | $14,901.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.19 / $1,362.07 / $2,666.21
| Professional | | $978.19 | $1,362.07 | $2,666.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.93 / $1,396.27 / $2,479.64
| Professional | | $1,060.93 | $1,396.27 | $2,479.64 |