- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,125.40 / $1,125.40 / $1,125.40
| Facility | | $1,125.40 | $1,125.40 | $1,125.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.97 / $1,125.40 / $1,450.31
| Professional | | $1,009.97 | $1,125.40 | $1,450.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,652.63 / $3,921.55 / $11,515.43
| Facility | | $1,652.63 | $3,921.55 | $11,515.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.64 / $1,721.03 / $2,515.37
| Professional | | $943.64 | $1,721.03 | $2,515.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,733.87 / $3,326.07 / $4,283.35
| Facility | | $2,733.87 | $3,326.07 | $4,283.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,686.61 / $2,144.52 / $2,144.52
| Professional | | $1,686.61 | $2,144.52 | $2,144.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.09 / $1,489.85 / $1,805.73
| Facility | | $1,207.09 | $1,489.85 | $1,805.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.18 / $1,207.09 / $2,239.50
| Professional | | $881.18 | $1,207.09 | $2,239.50 |
- 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
- $2,085.46 / $2,085.46 / $2,189.73
| Professional | | $2,085.46 | $2,085.46 | $2,189.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.33 / $1,227.33 / $1,227.33
| Professional | | $1,227.33 | $1,227.33 | $1,227.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,921.55 / $11,515.43 / $11,515.43
| Facility | | $3,921.55 | $11,515.43 | $11,515.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.67 / $1,285.01 / $2,515.37
| Professional | | $856.67 | $1,285.01 | $2,515.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.67 / $1,285.01 / $2,327.35
| Professional | | $856.67 | $1,285.01 | $2,327.35 |