- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,103.61 / $1,103.61 / $1,103.61
| Facility | | $1,103.61 | $1,103.61 | $1,103.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.61 / $1,103.61 / $1,916.59
| Professional | | $1,103.61 | $1,103.61 | $1,916.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,347.53 / $4,250.10 / $14,394.16
| Facility | | $1,347.53 | $4,250.10 | $14,394.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.47 / $1,804.01 / $2,466.67
| Professional | | $1,137.47 | $1,804.01 | $2,466.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,680.96 / $3,261.69 / $4,200.45
| Facility | | $2,680.96 | $3,261.69 | $4,200.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.39 / $2,241.17 / $2,241.17
| Professional | | $1,819.39 | $2,241.17 | $2,241.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,424.68 / $1,461.04 / $1,770.80
| Facility | | $1,424.68 | $1,461.04 | $1,770.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.02 / $1,040.02 / $3,478.88
| Professional | | $1,040.02 | $1,040.02 | $3,478.88 |
- 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
- $2,045.09 / $2,045.09 / $2,147.34
| Professional | | $2,045.09 | $2,045.09 | $2,147.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.56 / $1,448.56 / $1,448.56
| Professional | | $1,448.56 | $1,448.56 | $1,448.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,091.66 / $14,394.16 / $14,394.16
| Facility | | $6,091.66 | $14,394.16 | $14,394.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.67 / $1,350.19 / $2,466.67
| Professional | | $986.67 | $1,350.19 | $2,466.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.03 / $1,350.19 / $2,466.67
| Professional | | $1,097.03 | $1,350.19 | $2,466.67 |