- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $927.59 / $927.59 / $927.59
| Facility | | $927.59 | $927.59 | $927.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.59 / $1,004.13 / $1,359.71
| Professional | | $927.59 | $1,004.13 | $1,359.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,899.46 / $6,047.64 / $10,128.96
| Facility | | $1,899.46 | $6,047.64 | $10,128.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.20 / $1,577.08 / $2,073.23
| Professional | | $880.20 | $1,577.08 | $2,073.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,318.06 / $2,741.44 / $3,530.45
| Facility | | $2,318.06 | $2,741.44 | $3,530.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,529.18 / $1,636.65 / $1,636.65
| Professional | | $1,529.18 | $1,636.65 | $1,636.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,214.17 / $1,214.17 / $1,214.17
| Facility | | $1,214.17 | $1,214.17 | $1,214.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.34 / $1,214.17 / $2,521.50
| Professional | | $886.34 | $1,214.17 | $2,521.50 |
- 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
- $1,718.89 / $1,718.89 / $1,804.83
| Professional | | $1,718.89 | $1,718.89 | $1,804.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.50 / $1,310.50 / $1,310.50
| Professional | | $1,310.50 | $1,310.50 | $1,310.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,415.51 / $10,128.96 / $10,128.96
| Facility | | $4,415.51 | $10,128.96 | $10,128.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.83 / $1,059.14 / $2,073.23
| Professional | | $807.83 | $1,059.14 | $2,073.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.60 / $1,134.82 / $2,073.23
| Professional | | $821.60 | $1,134.82 | $2,073.23 |