- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,039.10 / $1,039.10 / $1,039.10
| Facility | | $1,039.10 | $1,039.10 | $1,039.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.10 / $1,039.10 / $1,339.10
| Professional | | $1,039.10 | $1,039.10 | $1,339.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,332.27 / $4,379.32 / $11,238.98
| Facility | | $1,332.27 | $4,379.32 | $11,238.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.28 / $1,430.15 / $2,322.48
| Professional | | $871.28 | $1,430.15 | $2,322.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,524.23 / $3,071.02 / $3,954.90
| Facility | | $2,524.23 | $3,071.02 | $3,954.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.28 / $1,833.41 / $1,833.41
| Professional | | $1,557.28 | $1,833.41 | $1,833.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.61 / $1,395.53 / $1,667.26
| Facility | | $1,375.61 | $1,395.53 | $1,667.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.74 / $1,018.74 / $2,500.88
| Professional | | $1,018.74 | $1,018.74 | $2,500.88 |
- 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
- $1,925.54 / $1,925.54 / $2,021.82
| Professional | | $1,925.54 | $1,925.54 | $2,021.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.60 / $1,180.60 / $1,180.60
| Professional | | $1,180.60 | $1,180.60 | $1,180.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,379.32 / $11,238.98 / $11,238.98
| Facility | | $4,379.32 | $11,238.98 | $11,238.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.98 / $1,186.47 / $2,322.48
| Professional | | $790.98 | $1,186.47 | $2,322.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.26 / $1,186.47 / $1,992.46
| Professional | | $804.26 | $1,186.47 | $1,992.46 |