- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.45 / $1,448.45 / $1,448.45
| Facility | | $1,448.45 | $1,448.45 | $1,448.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.45 / $1,611.24 / $2,786.69
| Professional | | $1,448.45 | $1,611.24 | $2,786.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,617.03 / $5,100.10 / $20,995.52
| Facility | | $1,617.03 | $5,100.10 | $20,995.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,617.03 / $2,548.54 / $3,237.38
| Professional | | $1,617.03 | $2,548.54 | $3,237.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,518.61 / $4,280.79 / $5,512.85
| Facility | | $3,518.61 | $4,280.79 | $5,512.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.73 / $2,941.40 / $2,941.40
| Professional | | $2,170.73 | $2,941.40 | $2,941.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,917.50 / $2,436.54 / $2,637.76
| Facility | | $1,917.50 | $2,436.54 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $2,637.76 / $4,727.25
| Professional | | $1,925.56 | $2,637.76 | $4,727.25 |
- 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
- $2,684.08 / $2,684.08 / $2,818.28
| Professional | | $2,684.08 | $2,684.08 | $2,818.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,106.17 / $2,106.17 / $2,106.17
| Professional | | $2,106.17 | $2,106.17 | $2,106.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,277.54 / $20,995.52 / $20,995.52
| Facility | | $8,277.54 | $20,995.52 | $20,995.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.22 / $1,848.23 / $3,237.38
| Professional | | $1,370.22 | $1,848.23 | $3,237.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.22 / $1,772.03 / $3,237.38
| Professional | | $1,378.22 | $1,772.03 | $3,237.38 |