- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,091.46 / $1,091.46 / $1,091.46
| Facility | | $1,091.46 | $1,091.46 | $1,091.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.46 / $1,091.46 / $1,723.30
| Professional | | $1,091.46 | $1,091.46 | $1,723.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,398.38 / $4,410.49 / $13,129.67
| Facility | | $1,398.38 | $4,410.49 | $13,129.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.93 / $1,669.13 / $2,439.48
| Professional | | $1,084.93 | $1,669.13 | $2,439.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,651.41 / $3,225.75 / $4,154.14
| Facility | | $2,651.41 | $3,225.75 | $4,154.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,799.33 / $2,216.46 / $2,216.46
| Professional | | $1,799.33 | $2,216.46 | $2,216.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,295.39 / $1,444.92 / $1,751.27
| Facility | | $1,295.39 | $1,444.92 | $1,751.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.63 / $1,295.39 / $2,904.00
| Professional | | $945.63 | $1,295.39 | $2,904.00 |
- 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
- $2,022.56 / $2,022.56 / $2,123.69
| Professional | | $2,022.56 | $2,022.56 | $2,123.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.91 / $1,700.91 / $1,700.91
| Professional | | $1,700.91 | $1,700.91 | $1,700.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,085.25 / $13,129.67 / $13,129.67
| Facility | | $5,085.25 | $13,129.67 | $13,129.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.80 / $1,335.30 / $2,439.48
| Professional | | $975.80 | $1,335.30 | $2,439.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.25 / $1,335.30 / $2,220.50
| Professional | | $1,034.25 | $1,335.30 | $2,220.50 |