- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,635.08 / $1,635.08 / $1,635.08
| Facility | | $1,635.08 | $1,635.08 | $1,635.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.08 / $1,695.65 / $2,928.02
| Professional | | $1,635.08 | $1,695.65 | $2,928.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,348.20 / $9,994.37 / $17,719.04
| Facility | | $3,348.20 | $9,994.37 | $17,719.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.72 / $2,750.58 / $3,654.52
| Professional | | $1,690.72 | $2,750.58 | $3,654.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,086.10 / $4,832.39 / $6,223.21
| Facility | | $4,086.10 | $4,832.39 | $6,223.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.48 / $3,320.41 / $3,320.41
| Professional | | $2,695.48 | $3,320.41 | $3,320.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,162.65 / $2,677.88 / $2,677.88
| Facility | | $2,162.65 | $2,677.88 | $2,677.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.85 / $2,677.88 / $4,370.63
| Professional | | $1,954.85 | $2,677.88 | $4,370.63 |
- 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
- $3,029.92 / $3,029.92 / $3,181.42
| Professional | | $3,029.92 | $3,029.92 | $3,181.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,197.44 / $2,197.44 / $2,197.44
| Professional | | $2,197.44 | $2,197.44 | $2,197.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,653.14 / $17,719.04 / $17,719.04
| Facility | | $7,653.14 | $17,719.04 | $17,719.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.81 / $2,000.36 / $3,654.52
| Professional | | $1,461.81 | $2,000.36 | $3,654.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.72 / $2,605.35 / $3,326.45
| Professional | | $1,690.72 | $2,605.35 | $3,326.45 |