- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $797.13 / $797.13 / $797.13
| Facility | | $797.13 | $797.13 | $797.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.13 / $886.71 / $1,683.79
| Professional | | $797.13 | $886.71 | $1,683.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $806.23 / $2,504.69 / $11,554.47
| Facility | | $806.23 | $2,504.69 | $11,554.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.80 / $1,402.54 / $1,781.63
| Professional | | $821.80 | $1,402.54 | $1,781.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,936.39 / $2,355.84 / $3,033.88
| Facility | | $1,936.39 | $2,355.84 | $3,033.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.63 / $1,618.74 / $1,618.74
| Professional | | $1,194.63 | $1,618.74 | $1,618.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,054.32 / $1,340.91 / $1,573.58
| Facility | | $1,054.32 | $1,340.91 | $1,573.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.71 / $1,573.58 / $2,820.00
| Professional | | $1,148.71 | $1,573.58 | $2,820.00 |
- 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
- $1,477.13 / $1,477.13 / $1,550.99
| Professional | | $1,477.13 | $1,477.13 | $1,550.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,938.02 / $11,554.47 / $11,554.47
| Facility | | $4,938.02 | $11,554.47 | $11,554.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.07 / $984.94 / $1,781.63
| Professional | | $754.07 | $984.94 | $1,781.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.08 / $1,261.08 / $1,261.08
| Facility | | $1,261.08 | $1,261.08 | $1,261.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.07 / $975.21 / $1,824.39
| Professional | | $754.07 | $975.21 | $1,824.39 |