- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,173.27 / $1,173.27 / $1,173.27
| Facility | | $1,173.27 | $1,173.27 | $1,173.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.27 / $1,173.27 / $1,511.99
| Professional | | $1,173.27 | $1,173.27 | $1,511.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,525.50 / $4,845.71 / $12,754.99
| Facility | | $1,525.50 | $4,845.71 | $12,754.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.78 / $1,614.80 / $2,622.33
| Professional | | $983.78 | $1,614.80 | $2,622.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,850.13 / $3,467.50 / $4,465.49
| Facility | | $2,850.13 | $3,467.50 | $4,465.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.34 / $2,208.11 / $2,208.11
| Professional | | $1,758.34 | $2,208.11 | $2,208.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.16 / $1,553.21 / $1,882.52
| Facility | | $1,544.16 | $1,553.21 | $1,882.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.24 / $1,544.16 / $2,767.50
| Professional | | $1,127.24 | $1,544.16 | $2,767.50 |
- 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
- $2,174.14 / $2,174.14 / $2,282.85
| Professional | | $2,174.14 | $2,174.14 | $2,282.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.40 / $1,455.40 / $1,455.40
| Professional | | $1,455.40 | $1,455.40 | $1,455.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,845.71 / $12,754.99 / $12,754.99
| Facility | | $4,845.71 | $12,754.99 | $12,754.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.10 / $1,339.65 / $2,622.33
| Professional | | $893.10 | $1,339.65 | $2,622.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.29 / $1,339.65 / $2,249.69
| Professional | | $912.29 | $1,339.65 | $2,249.69 |