- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,242.08 / $1,242.08 / $1,242.08
| Facility | | $1,242.08 | $1,242.08 | $1,242.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.08 / $1,242.08 / $2,302.15
| Professional | | $1,242.08 | $1,242.08 | $2,302.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,644.34 / $5,186.25 / $17,184.68
| Facility | | $1,644.34 | $5,186.25 | $17,184.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.29 / $2,105.41 / $2,776.18
| Professional | | $1,366.29 | $2,105.41 | $2,776.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,017.35 / $3,670.95 / $4,727.49
| Facility | | $3,017.35 | $3,670.95 | $4,727.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,047.65 / $2,522.37 / $2,522.37
| Professional | | $2,047.65 | $2,522.37 | $2,522.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,644.34 / $1,711.28 / $1,992.97
| Facility | | $1,644.34 | $1,711.28 | $1,992.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.23 / $1,711.28 / $3,489.38
| Professional | | $1,249.23 | $1,711.28 | $3,489.38 |
- 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
- $2,301.69 / $2,301.69 / $2,416.77
| Professional | | $2,301.69 | $2,301.69 | $2,416.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,739.96 / $1,739.96 / $1,739.96
| Professional | | $1,739.96 | $1,739.96 | $1,739.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,110.12 / $17,184.68 / $17,184.68
| Facility | | $6,110.12 | $17,184.68 | $17,184.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.58 / $1,519.59 / $2,776.18
| Professional | | $1,138.58 | $1,519.59 | $2,776.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.29 / $2,164.66 / $2,526.96
| Professional | | $1,366.29 | $2,164.66 | $2,526.96 |