- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $941.36 / $941.36 / $941.36
| Facility | | $941.36 | $941.36 | $941.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.36 / $958.44 / $1,356.78
| Professional | | $941.36 | $958.44 | $1,356.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,118.70 / $3,706.25 / $11,200.41
| Facility | | $1,118.70 | $3,706.25 | $11,200.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.19 / $1,532.20 / $2,104.00
| Professional | | $877.19 | $1,532.20 | $2,104.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,286.77 / $2,782.11 / $3,582.84
| Facility | | $2,286.77 | $2,782.11 | $3,582.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.87 / $1,660.94 / $1,660.94
| Professional | | $1,551.87 | $1,660.94 | $1,660.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,246.20 / $1,399.15 / $1,510.43
| Facility | | $1,246.20 | $1,399.15 | $1,510.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.38 / $1,399.15 / $2,507.63
| Professional | | $1,021.38 | $1,399.15 | $2,507.63 |
- 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
- $1,744.40 / $1,744.40 / $1,831.62
| Professional | | $1,744.40 | $1,744.40 | $1,831.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.76 / $1,426.76 / $1,426.76
| Professional | | $1,426.76 | $1,426.76 | $1,426.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,390.67 / $11,200.41 / $11,200.41
| Facility | | $4,390.67 | $11,200.41 | $11,200.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.07 / $1,074.84 / $2,104.00
| Professional | | $805.07 | $1,074.84 | $2,104.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.79 / $1,134.65 / $2,104.00
| Professional | | $818.79 | $1,134.65 | $2,104.00 |