- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,028.13 / $1,028.13 / $1,028.13
| Facility | | $1,028.13 | $1,028.13 | $1,028.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.13 / $1,142.08 / $1,562.15
| Professional | | $1,028.13 | $1,142.08 | $1,562.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,114.58 / $6,703.06 / $11,530.40
| Facility | | $2,114.58 | $6,703.06 | $11,530.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $999.10 / $1,785.79 / $2,297.92
| Professional | | $999.10 | $1,785.79 | $2,297.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.31 / $3,038.57 / $3,913.10
| Facility | | $2,569.31 | $3,038.57 | $3,913.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.82 / $1,814.05 / $1,814.05
| Professional | | $1,540.82 | $1,814.05 | $1,814.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,618.14 / $1,618.14 / $1,618.14
| Facility | | $1,618.14 | $1,618.14 | $1,618.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.24 / $1,618.14 / $2,837.63
| Professional | | $1,181.24 | $1,618.14 | $2,837.63 |
- 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
- $1,905.19 / $1,905.19 / $2,000.45
| Professional | | $1,905.19 | $1,905.19 | $2,000.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.04 / $1,819.04 / $1,819.04
| Professional | | $1,819.04 | $1,819.04 | $1,819.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,968.71 / $11,530.40 / $11,530.40
| Facility | | $4,968.71 | $11,530.40 | $11,530.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.88 / $1,186.91 / $2,297.92
| Professional | | $895.88 | $1,186.91 | $2,297.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.17 / $1,257.82 / $2,297.92
| Professional | | $919.17 | $1,257.82 | $2,297.92 |