- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,093.16 / $1,093.16 / $1,093.16
| Facility | | $1,093.16 | $1,093.16 | $1,093.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.96 / $1,093.16 / $1,408.75
| Professional | | $1,026.96 | $1,093.16 | $1,408.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,645.00 / $4,056.06 / $11,884.17
| Facility | | $1,645.00 | $4,056.06 | $11,884.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.60 / $1,671.72 / $2,443.29
| Professional | | $916.60 | $1,671.72 | $2,443.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,655.53 / $3,230.76 / $4,160.60
| Facility | | $2,655.53 | $3,230.76 | $4,160.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.12 / $2,288.81 / $2,288.81
| Professional | | $1,802.12 | $2,288.81 | $2,288.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.51 / $1,447.16 / $1,753.98
| Facility | | $1,172.51 | $1,447.16 | $1,753.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.93 / $1,172.51 / $2,316.38
| Professional | | $855.93 | $1,172.51 | $2,316.38 |
- 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
- $2,025.70 / $2,025.70 / $2,126.98
| Professional | | $2,025.70 | $2,025.70 | $2,126.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.81 / $1,223.81 / $1,223.81
| Professional | | $1,223.81 | $1,223.81 | $1,223.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,056.06 / $11,884.17 / $11,884.17
| Facility | | $4,056.06 | $11,884.17 | $11,884.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.12 / $1,248.18 / $2,443.29
| Professional | | $832.12 | $1,248.18 | $2,443.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.12 / $1,248.18 / $2,443.29
| Professional | | $832.12 | $1,248.18 | $2,443.29 |