- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.60 / $1,001.60 / $1,001.60
| Facility | | $1,001.60 | $1,001.60 | $1,001.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.48 / $1,001.60 / $1,450.90
| Professional | | $930.48 | $1,001.60 | $1,450.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,225.49 / $3,865.20 / $10,924.72
| Facility | | $1,225.49 | $3,865.20 | $10,924.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.51 / $1,400.88 / $2,238.64
| Professional | | $947.51 | $1,400.88 | $2,238.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,433.12 / $2,960.17 / $3,812.14
| Facility | | $2,433.12 | $2,960.17 | $3,812.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.19 / $2,033.98 / $2,033.98
| Professional | | $1,651.19 | $2,033.98 | $2,033.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.72 / $1,325.96 / $1,607.09
| Facility | | $1,232.72 | $1,325.96 | $1,607.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.89 / $1,232.72 / $2,209.13
| Professional | | $899.89 | $1,232.72 | $2,209.13 |
- 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
- $1,856.04 / $1,856.04 / $1,948.84
| Professional | | $1,856.04 | $1,856.04 | $1,948.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.58 / $1,096.58 / $1,096.58
| Professional | | $1,096.58 | $1,096.58 | $1,096.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,868.39 / $10,924.72 / $10,924.72
| Facility | | $3,868.39 | $10,924.72 | $10,924.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.09 / $1,225.36 / $2,238.64
| Professional | | $861.09 | $1,225.36 | $2,238.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.09 / $1,225.36 / $2,108.73
| Professional | | $861.09 | $1,225.36 | $2,108.73 |