- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,088.30 / $1,088.30 / $1,088.30
| Facility | | $1,088.30 | $1,088.30 | $1,088.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.30 / $1,088.30 / $1,458.03
| Professional | | $1,088.30 | $1,088.30 | $1,458.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,525.50 / $4,811.43 / $9,963.20
| Facility | | $1,525.50 | $4,811.43 | $9,963.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.38 / $1,601.78 / $2,432.42
| Professional | | $1,002.38 | $1,601.78 | $2,432.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,643.74 / $3,216.41 / $4,142.13
| Facility | | $2,643.74 | $3,216.41 | $4,142.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.00 / $2,210.04 / $2,210.04
| Professional | | $1,631.00 | $2,210.04 | $2,210.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.30 / $1,440.73 / $1,746.19
| Facility | | $1,167.30 | $1,440.73 | $1,746.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.13 / $1,167.30 / $2,803.50
| Professional | | $852.13 | $1,167.30 | $2,803.50 |
- 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
- $2,016.70 / $2,016.70 / $2,117.54
| Professional | | $2,016.70 | $2,016.70 | $2,117.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.88 / $1,186.88 / $1,186.88
| Professional | | $1,186.88 | $1,186.88 | $1,186.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,909.27 / $9,963.20 / $9,963.20
| Facility | | $4,909.27 | $9,963.20 | $9,963.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.98 / $1,331.43 / $2,432.42
| Professional | | $931.98 | $1,331.43 | $2,432.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.32 / $1,331.43 / $2,016.70
| Professional | | $948.32 | $1,331.43 | $2,016.70 |