- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,138.60 / $1,138.60 / $1,138.60
| Facility | | $1,138.60 | $1,138.60 | $1,138.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.60 / $1,138.60 / $1,710.96
| Professional | | $1,138.60 | $1,138.60 | $1,710.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,612.50 / $4,740.54 / $12,890.74
| Facility | | $1,612.50 | $4,740.54 | $12,890.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.11 / $1,693.13 / $2,544.87
| Professional | | $1,077.11 | $1,693.13 | $2,544.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,765.94 / $3,365.09 / $4,333.59
| Facility | | $2,765.94 | $3,365.09 | $4,333.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.06 / $2,312.21 / $2,312.21
| Professional | | $1,877.06 | $2,312.21 | $2,312.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.83 / $1,507.35 / $1,826.92
| Facility | | $1,271.83 | $1,507.35 | $1,826.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.44 / $1,271.83 / $2,707.13
| Professional | | $928.44 | $1,271.83 | $2,707.13 |
- 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
- $2,109.92 / $2,109.92 / $2,215.42
| Professional | | $2,109.92 | $2,109.92 | $2,215.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.14 / $1,293.14 / $1,293.14
| Professional | | $1,293.14 | $1,293.14 | $1,293.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,740.54 / $12,890.74 / $12,890.74
| Facility | | $4,740.54 | $12,890.74 | $12,890.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.43 / $1,392.99 / $2,544.87
| Professional | | $1,015.43 | $1,392.99 | $2,544.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.43 / $1,392.99 / $2,276.61
| Professional | | $1,015.43 | $1,392.99 | $2,276.61 |