- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,289.68 / $1,289.68 / $1,289.68
| Facility | | $1,289.68 | $1,289.68 | $1,289.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.68 / $1,289.68 / $2,380.03
| Professional | | $1,289.68 | $1,289.68 | $2,380.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,785.00 / $5,629.89 / $17,834.59
| Facility | | $1,785.00 | $5,629.89 | $17,834.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.51 / $2,176.64 / $2,882.53
| Professional | | $1,412.51 | $2,176.64 | $2,882.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,132.93 / $3,811.57 / $4,908.58
| Facility | | $3,132.93 | $3,811.57 | $4,908.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.09 / $2,618.98 / $2,618.98
| Professional | | $2,126.09 | $2,618.98 | $2,618.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,707.33 / $1,769.18 / $2,069.32
| Facility | | $1,707.33 | $1,769.18 | $2,069.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.50 / $1,769.17 / $3,935.63
| Professional | | $1,291.50 | $1,769.17 | $3,935.63 |
- 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
- $2,389.87 / $2,389.87 / $2,509.36
| Professional | | $2,389.87 | $2,389.87 | $2,509.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.82 / $1,798.82 / $1,798.82
| Professional | | $1,798.82 | $1,798.82 | $1,798.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,891.46 / $17,834.59 / $17,834.59
| Facility | | $6,891.46 | $17,834.59 | $17,834.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.09 / $1,594.21 / $2,882.53
| Professional | | $1,177.09 | $1,594.21 | $2,882.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.97 / $1,658.98 / $3,111.98
| Professional | | $1,281.97 | $1,658.98 | $3,111.98 |