- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,443.62 / $1,443.62 / $1,443.62
| Facility | | $1,443.62 | $1,443.62 | $1,443.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.62 / $1,505.83 / $2,604.67
| Professional | | $1,443.62 | $1,505.83 | $2,604.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,779.75 / $5,613.33 / $16,090.64
| Facility | | $1,779.75 | $5,613.33 | $16,090.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,532.03 / $2,382.42 / $3,226.60
| Professional | | $1,532.03 | $2,382.42 | $3,226.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,506.90 / $4,266.55 / $5,494.51
| Facility | | $3,506.90 | $4,266.55 | $5,494.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,163.52 / $2,931.61 / $2,931.61
| Professional | | $2,163.52 | $2,931.61 | $2,931.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,911.12 / $2,428.44 / $2,571.77
| Facility | | $1,911.12 | $2,428.44 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $2,571.77 / $4,608.75
| Professional | | $1,877.39 | $2,571.77 | $4,608.75 |
- 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
- $2,675.14 / $2,675.14 / $2,808.90
| Professional | | $2,675.14 | $2,675.14 | $2,808.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,213.75 / $2,213.75 / $2,213.75
| Professional | | $2,213.75 | $2,213.75 | $2,213.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,070.43 / $16,090.64 / $16,090.64
| Facility | | $8,070.43 | $16,090.64 | $16,090.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.64 / $1,766.14 / $3,226.60
| Professional | | $1,290.64 | $1,766.14 | $3,226.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.32 / $1,766.14 / $3,070.90
| Professional | | $1,488.32 | $1,766.14 | $3,070.90 |