- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.10 / $1,031.10 / $1,031.10
| Facility | | $1,031.10 | $1,031.10 | $1,031.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.10 / $1,043.57 / $1,960.94
| Professional | | $1,031.10 | $1,043.57 | $1,960.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,118.70 / $3,528.38 / $13,402.65
| Facility | | $1,118.70 | $3,528.38 | $13,402.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.70 / $1,793.37 / $2,304.59
| Professional | | $1,118.70 | $1,793.37 | $2,304.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,504.80 / $3,047.38 / $3,924.44
| Facility | | $2,504.80 | $3,047.38 | $3,924.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.29 / $2,093.90 / $2,093.90
| Professional | | $1,545.29 | $2,093.90 | $2,093.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,365.02 / $1,734.51 / $1,823.10
| Facility | | $1,365.02 | $1,734.51 | $1,823.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.86 / $1,823.10 / $3,267.38
| Professional | | $1,330.86 | $1,823.10 | $3,267.38 |
- 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
- $1,910.71 / $1,910.71 / $2,006.25
| Professional | | $1,910.71 | $1,910.71 | $2,006.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.08 / $1,482.08 / $1,482.08
| Professional | | $1,482.08 | $1,482.08 | $1,482.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,721.05 / $13,402.65 / $13,402.65
| Facility | | $5,721.05 | $13,402.65 | $13,402.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.83 / $1,315.70 / $2,304.59
| Professional | | $969.83 | $1,315.70 | $2,304.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.48 / $1,261.46 / $2,304.59
| Professional | | $898.48 | $1,261.46 | $2,304.59 |