- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,126.57 / $1,126.57 / $1,126.57
| Facility | | $1,126.57 | $1,126.57 | $1,126.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.24 / $1,126.57 / $1,625.57
| Professional | | $944.24 | $1,126.57 | $1,625.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,900.00 / $3,925.61 / $11,298.40
| Facility | | $1,900.00 | $3,925.61 | $11,298.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.19 / $1,900.00 / $2,517.96
| Professional | | $1,007.19 | $1,900.00 | $2,517.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,736.70 / $3,329.51 / $4,287.79
| Facility | | $2,736.70 | $3,329.51 | $4,287.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.20 / $2,287.75 / $2,287.75
| Professional | | $1,857.20 | $2,287.75 | $2,287.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,226.77 / $1,491.40 / $1,807.60
| Facility | | $1,226.77 | $1,491.40 | $1,807.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.54 / $1,226.77 / $2,241.75
| Professional | | $895.54 | $1,226.77 | $2,241.75 |
- 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
- $2,087.62 / $2,087.62 / $2,192.00
| Professional | | $2,087.62 | $2,087.62 | $2,192.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.59 / $1,228.59 / $1,504.40
| Professional | | $1,228.59 | $1,228.59 | $1,504.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,925.61 / $11,298.40 / $11,298.40
| Facility | | $3,925.61 | $11,298.40 | $11,298.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.75 / $1,378.26 / $2,517.96
| Professional | | $964.75 | $1,378.26 | $2,517.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.66 / $1,378.26 / $2,087.62
| Professional | | $981.66 | $1,378.26 | $2,087.62 |